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Date run 2/1/2013 10:42:49AM SAN J JIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <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. r� <br /> INFORMATION CHANGE(date) 7 <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0008488 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 <br /> Facility ID FA0010488 <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 Eli <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 New Account ID: <br /> Mail Invoices to Facility 1 Mail Invoices to: Owner 1 Facility I Account <br /> Account Name ULTRACA OF TON (Circle One) <br /> Account Balance as of 21112013: $3 .0 �v��" <br /> p4e,-C.T V C'" (Circle One) <br /> Transfer to ActiveRnacive <br /> mlElement and Description VR. ID Employee ID and Name Status New Owner? Delete <br /> WSMMBP-Common Materials PR052038 EE0006044-LOWELL ALLEN ctiv. Y N A D HW GEN<5 TONS/YR PR0514350 EE0004636-GARRETT BACKUS ctive' Y N A D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOPPR0512776 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 SURCH PR0534509 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.PHSlEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form f also certify that all operations will be performed in accordance with all applicable Ordinance Codes andror Standards and State anti <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date 1 I I�v <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date 1 I Q 1 f 3 <br /> Water System to be TRANSFERED: Amount Paid Date 1 ! <br /> Payment Typ Check Number Received by <br /> RENS: `-Z— Date 2— 1�_l� Account out: Date�_II r 3 <br /> COMMENTS: (( � <br /> .LJ C � '! f <br /> '� . e—tl <br />