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Date run 6/2/2008 4:02:04PM SAN QUIN COUNTY ENVIRONMENTAL HL FH DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 6/2/2008 Pagel <br /> Record Selection Criteria: Facility ID FA0014402 <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 OW0011444 New Owner ID : <br /> Owner Name T filaNtf Lycf,40 <br /> Owner DBA <br /> Owner Address 4 � <br /> J3 Of 9 <br /> Home Phone Not Specified 7 �f 0 <br /> Work/Business Phone 209-�-�#@71 IAC$ Z U <br /> Mailing Address PO BOX 584 <br /> KLAMATH FALLS, OR 976010032 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0014402 <br /> Facility Name C <br /> Location 4250 E MARIPOSA RD <br /> STOCKTON, CA 95215 <br /> Phone 209-9*3-3�4gg-�c8' /7c S1 Z — O <br /> Mailing Address PO BOX 584 <br /> KLAMATH FALLS, OR 976010032 <br /> Care of <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 AR0024482 New Account ID: <br /> Mail Invoices to Owner r Mail Invoices to: Owner / Facility / Account <br /> Account Name (Circle One) <br /> Account Balance as of 6/2/2008: $0.00 <br /> (Circle One) <br /> Transfer to Active/lnadve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2244-PACT TRANSFER RECORD-OES PR0519260 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this <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 and <br /> State and/or 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 Recei n <br /> REHS: Date / / Account out: <br /> COMMENTS: <br /> \\phs-ehsql-nt\apps\envisions\reports\5021.rpt <br />