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Date An 5/2; 008 320:43PN SAN JO IN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> Run by L Pagel <br /> - Facility Information as of 5/27/2008 <br /> Record Selection Criteria: Facility ID FA0005287 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0015119 New Owner ID <br /> Owner Name BUSTEZ ENTERPRISES INC <br /> Owner DBA <br /> Owner Address 15135 W EIGHT MILE RD <br /> STOCKTON, CA 95219 L /1 S <br /> Home Phone 209-951-4634 <br /> Work/Business Phone Not Specified //(jr.6 r hzEt <br /> Mailing Address 15135 W EIGHT MILE RD <br /> STOCKTON, CA 95219 7%/,r ��d T <br /> Care of SPURLOCK, CHUCK <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0005287 <br /> Facility Name H & H MARINA <br /> Location 15135 W EIGHT MILE RD �fie <br /> STOCKTON, CA 95219 <br /> Phone 209-951-4634 <br /> Mailing Address 15135 W EIGHT MILE RD <br /> STOCKTON, CA 95219 <br /> Care of CHUCK SPURLOCK <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 06908021 EMall: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name CHUCK SPURLOCK <br /> Title <br /> Day Phone 209-951-4634 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0005748 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name H & H MARINA (Circle one) <br /> Account Balance as of 5/27/2008: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0516679 EE0004636-GARRETT BACKUS Active Y N A 1 D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPR0511629 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2226-CalARP PROGRAM PR0514568 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0519562 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PRO501969 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> UNIFIED PROGRAM FAC STATE SURCHARPR0509341 EE0000000-HAZ MAT SJC OES Inactive Y N A I C <br /> 838 AST FAC>/=100 M+1 GAL CUMULATIVE PR0516678 EE0004636-GARRETT BACKUS Active Y N A I I <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHS/EHD hourly charges associated with it <br /> facility 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 Ordinace Codes and/or Standards an- <br /> State andlor Federal Laws. <br /> APPLICANT'S SIGNATURE: Date ! / <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date / ! <br /> Water System to be TRANSFERED: _*$372.00=— Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\phs-ehsql-nl\apps\envisions\reports\5021.rpt <br />