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nate run 5/4/2009 9:06:50AM SANXReport#5021 <br />Run by QUIN COUNTY ENVIRONMENTAL HEi' "H DEPARTMENT <br />`" Facility Information as of 5/4/ Pagel <br />.1 FAUUl sbl4 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0010643 <br />Owner Name <br />COLLICUT ENERGY SERVICES INC <br />Owner DBA <br />COLLICUT ENERGY SERVICES INC <br />Owner Address <br />3955 E ARCH RD <br />Phone <br />STOCKTON, CA 95215 <br />Home Phone <br />Not Specked <br />Work/Business Phone <br />209-462-1586 <br />Mailing Address <br />940 RIVERSIDE PKWY STE 80 <br />Location Code <br />W SACRAMENTO, CA 956051513 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0013514 <br />Facility Name <br />COLLICUT ENERGY SERVICES INC <br />Location <br />3955 E ARCH RD <br />STOCKTON, CA 95215 <br />Phone <br />209-462-1586 <br />Mailing Address <br />940 RIVERSIDE PKWY STE 80 <br />WEST SACRAMENTO, CA 95605 <br />Care of <br />Location Code <br />BOS District <br />APN 17926045 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0022618 <br />Mail Invoices to Facility <br />Account Name COLLICUT ENERGY SERVICES INC <br />Account Balance as of 5/4/2009: $0.00 <br />Description <br />Record ID Employee ID and Name <br />Make changesicorrections In RED Ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle Ons) <br />Transfer to ActmAnacNe <br />Status New Owrxe? Delete <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO517592 EE0000000 - HAZ MAT SJC DES Inactive Y N A T D <br />2244 - PACT TRANSFER RECORD - DES PR0521153 EE0000000 - HAZ MAT SJC DES Active Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHAReR0517591 EE0000000 - HAZ MAT SJC DES Inactive Y N A I D <br />BILLING and COMPLIANCE ACMOW LEDGEMENT: 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 volt be performed in accordance w#h all applicable Ordinace Codes andhor Standards and <br />State andlor Federal Laws. <br />APPLICANTS SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: • $20.00 = Amount Paid Date / I <br />Water System to be TRANSFERED: • $372.00 = Amount Paid Date /I <br />Payment T Check Number Recei <br />REHS: . (�f� /�IIZ r�� Dayte/J /A22q_ cw�unt/ou/k Drate` /{ l,/ <br />COMMENTS. � � � � ' \ K1 CJ f V - tT `/ �F-i / � !/ CJ J " O • �J � L) �V �� <br />\\eh-env\envision\reports\5021.rpt <br />