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Date nun .2/1/2013 10:42:49AM SAN JOIN COUNTY ENVIRONMENTAL HEALJfDEPARTMENT Repolt,15021 <br /> Run by Pagel <br /> Facility Information as of 2/1/2013 <br /> Record Selection Criteria: Facility ID FA0010488 <br /> Make changestcorrections in RED ink. / 2 <br /> INFORMATION CHANGE(date) f J <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSNI Fed Tax iD :. <br /> Owner ID OW0608488 Case Number: H08214 New Owner ID <br /> Owner Name CRAM, RICKY K <br /> Owner DBA ULTRACARE- STOCKTON <br /> Owner Address 2338 GARETH CIR <br /> STOCKTON, CA 95210 <br /> Home Phone 209_952-0391 <br /> Work/Business Phone 209-957-7841 <br /> Mailing Address 2338 GARETH CIR <br /> STOCKTON, CA 95210 <br /> Care of <br /> FACILITY FILE INFORMATION s j <br /> Facility ID FA0010488 a_S <br /> Facility Name ULTRACARE OF STOCKTON <br /> Location 4629 N WEST LN STE 10 <br /> STOCKTON, CA 95210 <br /> Phone 209-957-7841 <br /> Mailing Address 4629 N WEST LN STE#10 <br /> STOCKTON, CA 95210.,. <br /> Care of RICKY CHAM <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 10437014 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017488 r�-- :__ New Account ID: <br /> Mail Invoices to Facility �� Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name ULTR GA STOCKTON (Circle One) <br /> Account Balance as of 2111201 : $348.00 . '/`� V <br /> r'� V�" � _� (Circle One) <br /> Transfer to AcliveAnacive <br /> ProgranVElement and Description ecord ID— Employee Employee ID and Name Status New Owner? Delete <br /> 19 BP Common Materials —PR85203 EE0006044-LOWELL ALLEN Y N A ' D <br /> 2220-SM HW GEN<5 TONSIYR PRO514350 EE0004636-GARRETT BACKUS cave Y N A D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPR0512776 EE0000000-HAZ MAT SJC OES Inac Ive Y N A, I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0510488 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHiPR0534509 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I.the undersigned owner,operator or agent of same,acknowledge that all site,andfor 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 accordance with all applicable Ordinance Codes andbr Standards and Stale anlcr <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date ! 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Typ Check Number Received by <br /> REHS: 1-0,5 e–"�- Date Z- I�ITL Account out: Date I 1 <br /> COMMENTS: I I <br /> r � rr'� O �'� � I t I � <br /> A00 �� �0 �-�L 0 c'C'- f r <br /> • t <br />