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Date run 9/16/2014 3:26:28PR SAN JO, JIN COUNTY ENVIRONMENTAL HEAI DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9/16/2014 <br /> Record Selection Criteria: Facility ID FA0009902 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 10 SSN/Fed Tax ID <br /> Owner ID OW0007847 Case Number: H05625 New Owner ID <br /> Owner Name CITY OF STOCKTON - PARKS & REC <br /> Owner DBA <br /> Owner Address 6 E LINDSAY ST <br /> STOCKTON, CA 95202 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-937-8206 <br /> Mailing Address 6 E LINDSAY ST <br /> STOCKTON, CA 95202-1997 <br /> Care of CRUZ, ADOLFO <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0009902 10183011 <br /> Facility Name STKN SWENSON GOLF COURSE <br /> Location 6803 ALEXANDRIA PL <br /> STOCKTON, CA 95207 <br /> Phone 209-937-7361 x0 <br /> Mailing Address 6 E LINDSAY ST <br /> STOCKTON, CA 95202-1997 <br /> Care of Stockton Swenson Golf Course <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 09711024 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 AR0016902 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name CITY OF STOCKTON - PARKS & REC (Circle One) <br /> Account Balance as of 9/16/2014: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Prograrn/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PR0519946 EE0000006-HAZA SAEED Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0539043 EE0000005-FATINAH ZAREEF Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512190 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2226-CaIARP PROGRAM PR0514696 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0509902 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532235 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 facility <br /> 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 Ordinance Codes andror Standards and State andlor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br />