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Date run 2/14/2014 2:43:37PR SAN JOUIN COUNTY ENVIRONMENTAL HEAT 1 DEPARTMENT Report#5021 <br /> ` <br /> Rud by lfls/' Pagel <br /> Facility Information as of 2/14/20 <br /> Record Selection Criteria: Facility ID FA0003660 <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 OW0002730 New Owner ID <br /> Owner Name PQQJ p <br /> Owner DBA ^�T4afAE4.,T-ER <br /> Owner Address P0130 -aQQ38 <br /> ST1&G4TQI„Q,A95213 <br /> Home Phone ( QLSpii ed <br /> Work/Business Phone 209-465-4500 <br /> Mailing Address PL-LOX 30038 <br /> ST-15W 95213 <br /> Care of At}T-g1dEtg{{R j0 <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0003660 ��� <br /> Facility Name 1gy$gyTE�. J <br /> Location 2735 N TEEPEE DR A <br /> STOCKTON, CA 95205W <br /> " <br /> Phone 209-0£53590 yVl� — '� ^ <br /> Mailing Address A 1:'? t) M�� [,prM f (,V.. im' - <br /> 5 <br /> care of AUTOMEISTER <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOIS District 002- RUHSTALLER, LARRY Fax <br /> APN 13208030 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name A }6TZR <br /> Title <br /> Day Phone20gJ-3WQ <br /> Night Phone 20geg� <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003238 New Account ID: <br /> Mail lnvoicesto Facility Mail Invoices to Owner / Facility / Account <br /> Account Name AUTOMEISTER (Circle One) <br /> Account Balance as of 2/14/2014: $0.00 <br /> (Cimle One) <br /> Transfer to ActiveMactve <br /> PrograrNElement and Description Record ID Employee ID and Name Status New Omen Delete <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0232567 EE0000008-LETITIA BRIGGS Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,arhnowledge that all site,antax project specific,PHSEHD hourly charges associated with this facility <br /> or activity will he 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 anuor Standards and State andlor <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 T e Check Number Received �f <br /> REHS: - U�(NtJ Date / I Account out: Date 2 mac 1 <br /> COMMENTS: <br /> neo P [ � z '0 <br /> �� 1 k291C26a6? r� <br />