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Date run 2/11/2014 9:06:47AN SAN JOIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report 05021 <br /> Run by 12731- r Pagel <br /> Facility Information as of 2/11/2014 <br /> Record Selection Criteria: Facility ID FA0010461 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0008461 Case Number: H08146 New Owner ID <br /> Owner Name CALIF DEPT OF BOATING &WATERW <br /> Owner DBA CALIFORNIA DEPT OF BOATING &W <br /> OwnerAddress 2000 EVERGREEN 100 L 41 <br /> SACRAMENTO, CA <br /> Home Phone Not Specified <br /> Work/Business Phone 916-212-3845 <br /> Mailing Address 2000 EVERGREEN SUITE#100 L L rA�,—s 6TE 41,P_ <br /> SACRAMENTO, CA 95Bt5389G 9a"-e>14 - U `77 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0010461 10,183,571 <br /> Facility Name CALIF DEPT OF BOATING &WATERWAYS <br /> Location 8095 RIO BLANCO RD <br /> STOCKTON, CA 95219 <br /> Phone 916-212-3845 x0 <br /> Mailing Address 2000 EVERGREEN SUITE#100 l t-/y <br /> i47v Ii — �-TTr— L{ 10 <br /> SACRAMENTO, CA 968463896- JO&AIll7 <br /> Care of <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOB District 003 - BESTOLARIDES Fax <br /> APN 06605052 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 AR0017461 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name CALIF DEPT OF BOATING &WATERW (Circle One) <br /> Account Balance as of 2/11/2014: $350.00 <br /> (Circle One) <br /> Transfer to Activellnachie <br /> Program/Element and Description Record ID Employee ID and Name status New Omen Delete <br /> 1921 -HMBP-Regular-Primary Location PRO520335 EE0006044-LOWELL ALLEN Active Y N A 1 D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO512749 EE0000000-HAZ MAT SJC OES Inadivr Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0510461 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO533071 InactivE Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,me undersigned owner,operator or agent of same,acknowledge that all site,anclor project speu(ic,Phil 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 accordance with all applicable Ordinance Codes andfor Standards and State andfor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date_/ /_ <br /> Payment Type Check Number Receivy <br /> REHS: Date_/ I Account out: Date <br /> COMMENTS: <br /> (ylyC-a�IG/(�lrttl/J�t�^-uA'ly\ <br />