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Date run 11/4/2005 4:04:30PA SAN JUIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report #5021 Run by 8006 Pagel Facility Information as of 11/4/20 Record Selection Criteria: Facility ID FA0003919 OWNER FILE INFORMATION Owner ID OW0000835 owner Name VAN DE POL ENTERPRISES Owner DBA 5491 F ST Owner Address 1001 W CHARTER WAY Phone STOCKTON, CA 95206 Home Phone Not Specified Work/Business Phone 209-944-9115 Mailing Address PO BOX 1107 STOCKTON, CA 95201 Care of FACILITY FILE INFORMATION Facility ID FA0003919 Facility Name VAN DE POL ENTERPRISES Location 5491 F ST A BANTA, CA 95304 Phone 209-835-2750 Mailing Address PO BOX 1107 STOCKTON, CA 952011107 Care of TOM VAN DE POL Location Code 99 - UNINCORPORATED AREA BOS District 005 - ORNELLAS, LEROY ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0003511 Mail Invoices to Facility Account Name VAN DE POL ENTERPRISES Account Balance as of 11/4/2005: $0.00 Program/Element and Description Record ID 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATIOIPR0513526 2244 - PACT TRANSFER RECORD - OES PRO520770 2301 - UST STATE SURCHARGE FEE PRO507703 2381 - UST FACILITY (BEFORE 1/84) - obsolete PR0231502 2399 - UNIFIED PROGRAM FAC STATE SURCHARPR0507525 2399 - UNIFIED PROGRAM FAC STATE SURCHARIPRO511238 Employee ID and Name ake changes/corrections in RED ink or pencil. INFORMATION CHANGE (date) _ OWNERSHIP CHANGE (date) _ New Owner ID Site Mitigation Facility APN 25008019 SIC Code:9900 New Account ID: : Mail Invoices to: Owner / Facility / Account (Circle One) EE0000000 - HAZ MAT SJC DES EE0000000 - HAZ MAT SJC DES EE0000451 - STEVE SASSON EE0000451 - STEVE SASSON EE0000451 - STEVE SASSON EE0000000 - HAZ MAT SJC DES (Circle One) Transferlo Aclive/Inaclve Status Naw Omer?Delete Inactive Y N A I D Active Y N A 1 D Inactive Y N A I D Inactive Y N A I D Inactive Y N A I D Inactive Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project spec, PHS/EHD hourly charges associated vdth this facility or activity will be billed to the party idenfified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes andlor Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number REHS: _ COMMENTS $20.00 = ' $372.00 = _ Date A-zDLn ,13,rD \\phs-ehsgl-nt\apps\envisions\reports\5021. rpt Date Amount Paid Date Amount Paid Date Received by Account out: Date / if -7 1�