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Dale r n 12/10/2008 2:49:09P SAN J 'QUIN COUNTY ENVIRONMENTAL HE!- TH DEPARTMENT Report x5021 <br /> Run by <br /> 1.00 Facility Information as of 12/10/M6 Papel <br /> Record Selection Criteria. Facility ID FA0013518 <br /> Make changesicorrections in RED Ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0010634 New Owner ID <br /> Owner Name S J CO PUBLIC WORKS DEPT <br /> Owner DBA <br /> Owner Address 1702 E SCOTTS AVE <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 1702 E SCOTTS AVE <br /> STOCKTON, CA 95205 <br /> Care of SJ CO PUBLIC WORKS DEPT <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013518 <br /> Facility Name PUBLIC WORKS/ UTILITY SANTOS#2 <br /> Location LOS POSITAS til $I Las PotoPrAs U qa <br /> TRACY, CA 95376 <br /> Phone <br /> Mailing Address 1702 E SCOTTS AVE <br /> STOCKTON, CA 95205 <br /> Care of GUZMAN, BEN <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0022622 New Account 10: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name PUBLIC WORKS/UTILITY SANTOS#2 (OIroM One) <br /> Account Balance as of 12/10/2008: $0.00 <br /> (Circle Oro) <br /> Transfer to Actn e/Inactve <br /> Program/Element am Description Record ID Employee ID and Name Slates New Owner? Delete <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO517603 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPR0517602 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. 1,Me w+derslgned pwner,operator or agent of same,acknowledge trial all site.ani project specific.PHS/EHD roboy charges assocated with this <br /> Wily or activity will be billed to the party idemlfied as the OWNER on dYs rope. I also certify Mat all operations wdl be performed in accordance with all applicable Ordinace Codes andlor Standards a+tl <br /> Stale and/or Federal Laws. <br /> APPLICANTS 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 Reoeivl. b <br /> REHS: W-Nx^ Date 11 00 0 /0% Account out: Date .)aj <br /> COMMENTS: <br /> \\phs-ehsq I-nt\apps\envisions\reports\5021.rpt <br />