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Date run 2/25/2015 10:41:24AI SAN J IN COUNTY ENVIRONMENTAL HEAW DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/25/2015 <br /> Record Selection Criteria: Facility ID FA0003879 <br /> Make changes/connections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 86 SSN/Fed Tax ID <br /> Owner ID OW0001176 New Owner ID <br /> Owner Name CITY OF STOCKTON <br /> Owner DBA <br /> Owner Address 425 N EL DORADO ST <br /> STOCKTON, CA 95202 <br /> Home Phone 209-937-8212 <br /> Work/Business Phone 209-937-8341 <br /> Mailing Address 425 N EL DORADO ST <br /> STOCKTON, CA 95202 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0003879 10181503 <br /> Facility Name CITY OF STOCKTON FIRE STATION#11 <br /> Location 1211 E SWAIN RD <br /> STOCKTON, CA 95210 <br /> Phone 209-937-8801 x <br /> Mailing Address 1211 E SWAIN RD <br /> STOCKTON, CA 95210 <br /> Care of STOCKTON FIRE STATION #11 <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOB District Fax <br /> APN 09405009 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 AR0003467 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name City 9fR 0' e a It (Circle One) <br /> Account Balance as of 2/25/2 135.00 <br /> (Circle One) <br /> Transfer to Activellnal <br /> PrograrNElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0539638 EE0000006-HAZA SAEED Active,l Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512081 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0232404 EE0000451 -STEVE SASSON Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0509793 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PRO528816 EE0000005-FATINAH ZAREEF Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as Me OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andfor Standards and State anNor <br /> Federal Laws. <br /> APPLICANT'S 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 Received/b _ <br /> REHS: Date Account out: ✓1✓ Date <br /> COMMENTS: 1 / _ <br />