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Date nm 12/17/2014 2:06:04P SAN JUIN COUNTY ENVIRONMENTAL HEA Report #5021 DEPARTMENT pages <br />Run by <br />Facility Information as of 12/17/2014 <br />Record Selection Criteria: Facility ID FA0003919 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />owner ID OW0000835 <br />Owner Name VAN DE POL ENTERPRISES <br />Owner DBA <br />Owner Address 1001 W CHARTER WAY <br />STOCKTON, CA 95206 <br />Home Phone Not Specified <br />Wolk/Business Phone 209-944-9115 <br />Mailing Address PO BOX 1107 <br />STOCKTON, CA 95201 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility lD/CERS ID <br />FA0003919 10181517 <br />Facility Name <br />VAN DE POL ENTERPRISES <br />Location <br />5491 F ST <br />A I D <br />BANTA, CA 95304 <br />Phone <br />209-835-2750 x <br />Mailing Address <br />PO BOX 1107 <br />N <br />STOCKTON, CA 95201-1107 <br />Care of <br />TOM VAN DE POL <br />Location Code <br />99 - UNINCORPORATED P <br />BOS District 005 -ELLIOTT, BOB <br />APN 25008022 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0003511 <br />Mail Invoices to Facility <br />Account Name VAN DE POL ENTERPRISES <br />Account Balance as of 12/17/2014: $0.00 <br />Program/Element and Description <br />Make changes/comections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN /Fed Tax ID <br />New Owner ID <br />Site Mitigation Facility <br />Alt Phone <br />Fax <br />EMail : <br />New Account ID: <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />Record ID Employee ID and Name <br />(Circle One) <br />Transfer to ActivainacNe <br />Status New Owner! Delete <br />1921 - HMBP-Regular-Primary Location <br />PR0520770 <br />EE0002474 - MICHAEL PARISSI <br />Active <br />Y <br />N <br />A I D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION <br />PRO513526 <br />EE0000000 - HAZ MAT SJC DES <br />Inactive <br />Y <br />N <br />A I D <br />2301 - UST STATE SURCHARGE FEE <br />PR0507703 <br />EE0000451 - STEVE SASSON <br />Inactive <br />Y <br />N <br />A I D <br />2381 - UST FACILITY (BEFORE 1/84) - obsolete <br />PR0231502 <br />EE0000451 - STEVE SASSON <br />Inactive <br />Y <br />N <br />A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F <br />PR0507525 <br />EE0000451 - STEVE SASSON <br />Inactive <br />Y <br />N <br />A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F <br />PR0511238 <br />EE0000000 - HAZ MAT SJC DES <br />Inactive <br />Y <br />N <br />A I D <br />+2.eS4, AST FAC >/= 1,320 - <10 K GAL CUMULATIVE <br />PR0524701 <br />EE0002646 - THUY TRAN <br />Active <br />Y <br />N <br />A I D <br />ERSC `ELECTRONIC REPORTING STATE SURCHARG <br />PR0531467 <br />Inactive <br />Y <br />N <br />A I D <br />'ZVLDNG and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andfor project specific, PHSrEHD 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 andfor Standards and Stale andfor <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: _. <br />Payment Type Check Number <br />GTlD�ate 5�yAccount out: ReceivDateREHS: � <br />COMMENTS: 7-163 0' "4'-6-.nb_rr 7_ <br />/ ZOsqDate <br />$25.00 = Amount Paid Date <br />Amount Paid Da <br />