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Date run 5/4/2009 3:41:56PM SAN JOA("'IN COUNTY ENVIRONMENTAL HEAL --—DEPARTMENT <br />Run by <br />Facility Information as of 5/4/2009 <br />Record Selection Criteria: Facility ID FA0010903 ON <br />1: MCI Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION SSN / Fed Tax ID <br />Owner ID OW0008903 Case Number: H08953 New Owner ID <br />Owner Name STATE OF CALIFORNIA <br />Owner DBA <br />Report #5021 <br />Pagel <br />Owner Address <br />1252 N STANISLAUS ST <br />STOCKTON, CA 95202 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-467-5311 <br />Mailing Address <br />1252 N STANISLAUS ST <br />STOCKTON, CA 95202 <br />Care of <br />FACILITY FILE INFORMATION <br />Site Mitigation Facility <br />Facility ID <br />FA0010903 <br />Facility Name <br />CSU STANISLAUS MULTI CAMPUS REGION <br />Location <br />Phone <br />209-467-5318 <br />Mailing Address <br />c� <br />6 b �'�' Ci A c x G i cL <br />qR� <br />02 <br />S—!'O -f'aYt C 4 s Zs7 Z <br />Care of <br />&T_ VS F T4 4nr' � 44A8-- <br />Location Code <br />Alt Phone i <br />BOS District <br />Fax <br />APN <br />13921008 <br />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 AR0017903 <br />Mail Invoices to Account <br />Account Name CSU STANISLAUS MULTI CAMPUS REGIONA <br />Account Balance as of 5/4/2009: $0.00 <br />Program/Element and Description <br />Record ID Employee ID and Name <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Status New Owner? Delete <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO513191 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARPR0510903 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />2831 - AST FAC >/= 1,320 - <10 K GAL CUMULATRPR0528340 EE0009488 - JEFFREY WONG Active 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 spec, 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: <br />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 Received by <br />REHS:Date / Account out: vr,__ Date S/ <br />COMMENTS: <br />\\eh-env\envision\reports\5021. rpt <br />