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Date run 1/22/2009 2:1,9:26PR SAN JO' -%UIN COUNTY ENVIRONMENTAL HEAT mH DEPARTMENT x ! Report 65021 <br /> Run by .M, ..�.�,... ... .. ..-. ,- <br /> Facility Information as of 1122120. 3 Pagel <br /> .Record Selection Criteria: Facility ID FA0010854 <br /> Make changesicorrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date). <br /> OWNER FILE INFORMATION SSN 1 Fed Tax ID <br /> w 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 /> Work1B6sIness Phone 209-468-3091 <br /> Mailing Addr <br /> 0 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> FacilityID FA0010854 <br /> Facility Name SJC PUBLIC WORKS/UTILITY-ACAMPO MA <br /> Location-20680-SYCAMORE ST <br /> ACAMPO, CA 95220 <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 004-VOGEL, KEN Fax <br /> APN 01320044 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 AR0017854 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name SJC PWD UTILITIES MAINTENANCE DISTS (Circle One) <br /> Account Balance as of 112212009: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> ProgramlElement and,Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO513142 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPRO510854 EE0000000-HAZ MAT SJC OES Inactive Y N A 'I D <br /> 28401-AST EXEMPT FAG < 1,320 GAL PR0529082 EE0000753-WILLY NG Active,Exempt 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,PHSIEHD hourly charges associated with oris <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 Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANTS SIGNATURE: Date 1 / <br /> Program Records to be TRANSFERED: $20.00= Amount Paid Date 1 / <br /> Water System to be TRANSFERED: '$372.00= Amount PaidD e <br /> Payment Type Check Number Re <br /> RENS: Date 1 ZZ' 1 drl' Account out: Date�1 <br /> COMMENTS: ^. <br /> O`RAr`4 C-- <br /> lleh-envlenvisionlreports15021.rpt <br /> 3 <br />