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,•aterun 3/1112013 11:14:46AI SAN JO! TIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by WAi *+* Page) <br /> Facility Information as of 3/11/2013 <br /> Record Selection Criteria: Facility ID FA0016214 <br /> Make changes/corrections in RED ink. f <br /> INFORMATION CHANGE(date) / 3 <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN I Fed Tax ID <br /> Owner ID OW0013110 New Owner ID <br /> Owner Name TOM SAUREY <br /> Owner DBA TUFF SHED <br /> Owner Address 2829 S HIGHWAY 99 RD <br /> STOCKTON, CA 95215 z ill <br /> Home Phone Not Specified <br /> Work/Business Phone 209-455-3388 <br /> Mailing Address 2829 S HIGHWAY 99 RD <br /> STOCKTON, CA 95215 C,4 Z�S� <br /> Care of <br /> FACILITY FILE INFORMATION <br /> - Facility ID FA00116214 <br /> Facility Name TUFF SHED <br /> Location 2829S HWY 99 FRONTAGE RD <br /> STOCKTON, CA 95219 S;—U t. T—ill.—I C,,4 5�2_o <br /> Phone 209-4165-3388 x0 <br /> Mailing Address 2829 C HIGH>nrnv oo nn S c� fI 3C ti r <br /> Care of <br /> Location Code Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 17911010 EMail:. <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0028337 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name TOM SA (Circle one) <br /> Account Balance as of 3/11/201 <br /> (Circle One) <br /> Transfer to Activellnacive <br /> Pro ram7Elament and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920- MBP-Common Materials PRO524123 EE0006044-LOWELL ALLEN Active Y N A I D <br /> C-ELECTRONIC REPORTING STATE SURCHPR0533544 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ander project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form I also certify that all operations will be performed in arcordance with all applicable Ordinance Codes andtor Standards and Slate andor <br /> Federal Laws, <br /> APPLICANT'S SIGNATURE: Date / f <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date f 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 I <br /> Payment Type Check Number Received by <br /> REHS: � Date 3 ! 1 ,1'3 Account out: /} Date 1 // 1{ /� <br /> COMMENT-` (/V T (� I} 1 1� <br /> 1Vv }�' �u y {L 1 <br />