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Report#5021 <br /> =by <br /> 2:55:OBP1 SAN JOIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Paget <br /> Facility Information as of 5/21/2013 <br /> Record Selection Criteria: Facility ID FA0010055 <br /> Make changes/corrections in RED ink. <br /> 1 INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSNI Fed Tax ID <br /> owner ID OW0008055 Case Number: H06387 New Owner ID <br /> Owner Name CALIFORNIA DEPT FISH &GAME <br /> Owner DBA CALIFORNIA DEPT FISH & GAME <br /> Owner Address 4001 N WILSON WAY <br /> STOCKTON, CA 952052486 <br /> Home Phone Not Specified <br /> Work/Business Phone 916-653-7667 <br /> Mailing Address 4001 N WILSON WAY <br /> STOCKTON, CA 952052486 <br /> Care of MARTYGINGRAS <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0010055 10,183,167 <br /> Facility Name CALIFORNIA DEPT FISH &GAME <br /> Location 4001 N WILSON WAY <br /> STOCKTON, CA 952052420 <br /> Phone 209-948-7800 <br /> Mailing Address 4001 N WILSON WAY <br /> STOCKTON, CA 952052486 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 13202008 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name I� <br /> Title <br /> Day Phone 1 �� <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account lD <br /> AR0017055 \v 8 New Account ID: <br /> Mail Invoices to Account -Mail Invoices to: Owner / Facility / Account <br /> \ (circle one) <br /> Account Name CALIFORNIA DEPT FISH &GAIii <br /> Account Balance as of 5/21/2013: $0.00 Circle one) <br /> Transfer to Activellneclve <br /> PrograMElement and Description Record ID Employee ID and Name <br /> Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO520047 EE0006044-LOWELL ALLEN Active Y N A D <br /> 1962-CalARP PROGRAM 2 FACILITY PRO527103 EE0000988-KASEY FOLEY Active Y N A I D <br /> 1995-CaIARP FAC STATE SURCHARGE FEE 17 <br /> SM HW <br /> 2220-SM HW GEN c5 TONS/YR PRO5144EE0004636-GARRETT BACKUS Active Y N A I D <br /> 2226-CaIARP PROGRAM PR0514720 EE0000000-HAZ MAT SJC OES Inactive Y N A <br /> 2245-PACT TRANSFER RECORD-SUPPLEMENTAL PRO512343 EE0008709-JAMIE DELA ROSA Inactive Y N A 1 D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0510055 EE0000000-HAZ MAT SJC OES Inactive <br /> Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0531249 pHS/E active) charges associated with this fatilily <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowletlga that all site,and it proiect specific, Y <br /> or activity will be billed to the party identified as the OWNER on this forth I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards end State enaor <br /> Federal Laws <br /> Date <br /> APPLICANT'S SIGNATURE: <br /> Amount Paid Date <br /> Program Records to be TRANSFE "825.00= Amount Paid Date <br /> Water System to be TRANSFERER:D: Receiv d !i <br /> PaymentType ,Fheck/N`umber Date Account out: <br /> -RENS1': l <br /> Htl4r: QU-(J -7 l 3 l (3 <br />