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Date run 2/14/2014 8:21:23AA SAN JOO7IN COUNTY ENVIRONMENTAL HEA DEPARTMENT <br /> Report#5021 <br /> Runty Pagel <br /> Facility Information as of 2/14/2014 <br /> Record Selection Criteria: Facility ID FA0011014 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0009014 Case Number: H09156 New Owner ID <br /> Owner Name VERY, BRIAN D <br /> Owner DBA ELESCO <br /> Owner Address 170 MCCORMICK AVE G <br /> COSTA MESA, CA 926263307 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-464-2288 <br /> Mailing Address 170 MCCORMICK AVE <br /> COSTA MESA, CA 926263307 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0011014 10,184,033 �•L <br /> Facility Name ELESCO <br /> Location 2569'TEEPEE D <br /> STOCKTON, CA 95205 <br /> Phone 209-464-2288 <br /> Mailing Address 170 MCCORMICK AVE <br /> COSTA MESA, CA 926263307 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 13208007 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION ` l„ ` <br /> Account ID AR0018014 D J New Account ID: <br /> 1I I I 1 (Circle One) <br /> Mail Invoices to: Owner I Facility / Account <br /> Mail Invoices to Facility <br /> Account Name ELESC <br /> Account Balance as of 2/14/201 . 1 2 U <br /> (Circle One) <br /> Transferto ActivellnacNe <br /> ProgramlElemenl and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PR0520607 EE0008709-JAMIE DE LA ROSA Active Y N A© D <br /> 2220-SM HW GEN<5 TONS/YR PRO514492 EE0009488-JEFFREY WONG Inactive Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO513302 EE0000000-HAZ MAT SJC I Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0511014 EEOOOOOOO-HAZ MAT SJC DES Inactive Y N A 1 0 <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO531461 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1.the undersigned owner,operator or agent of same,acknowledge that all site,ani protect specific,PHSEHD hourly charges associated wit a -ity <br /> or activity will be billed to the party identified as the OWNER on this form l also partly,Nat all operations Wit be performed in accordance with all applicable Ordinance Codes ander Standards State an or <br /> Federal Laws. ,l{ <br /> APPLICANTS SIGNATURE: Date n �'Fi <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date_/ n <br /> Water System to be TRANSFERED: Amount Paid Date / / (�I <br /> Payment T a ,- heck NumberRec i <br /> REHS: y r N r yw' Date / Account out: Date <br /> COMMENTS: e I O <br /> S 4'*461L� v 8 � , urM1 uta <br />