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Date run 12/10/2008 8:43:41A SAN JOA-` TfIN COUNTY ENVIRONMENTAL HEAL""'DEPARTMENT Report#5021 <br /> Run by 1273 Pagel <br /> Facility Information as of 12/10/20 <br /> Record Selection Criteria: Facility ID FA0010856 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN I Fed Tax ID <br /> Owner ID OW0008853 Case Number: H08879 New owner ID <br /> Owner Name SAN JOAQUIN COUNTY <br /> Owner DBA <br /> Owner Address 1702 E SCOTTS AVE <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-468-3091 <br /> Mailing Address 19847 GREENVIEW DR <br /> ACAMPO, CA 95220 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010856 <br /> FacilityName SJC PUBLIC WORKS/UTILITY-HSPTL LIF / <br /> Location J VAT\4C.,✓S 42--9 ALO <br /> FRENCH CAIMP,--C—A CAMP,--C-A95231 <br /> Phone 209-468-3090 <br /> Mailing Address 1702 E SCOTTS AVE <br /> STOCKTON, CA 95205 <br /> Care of WILLIAM G ARBOGAST <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 001 - GUTIERREZ, STEVE Fax <br /> APN 19305008 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017856 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner I Facility / Account <br /> AeeountName SJC PWD UTILITIES MAINTENANCE DISTS (Circle One) <br /> Account Balance as of 1211012008: $0.00 <br /> (Circle One) <br /> Transfer to Active/lnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO513144 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR1PR0510856 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: t,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project spec fic,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the parry identified as the OWNER on this form_ I also certify that al operations will be pefformed in accordance with all applicable Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / 1 <br /> Program Records to be TRANSFERED: "$20.00= Amount Paid Date / ! <br /> Water System to be TRANSFERED: `$372.00= Amount Paid Date / 1 <br /> Payment Type Check Number Recei y <br /> RENS: Date I ! Account out: — Date�l 1 <br /> COMMENTS: <br /> llphs-ehsgl-ntlappslenvisionslreports15021.rpt <br />