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Date run 2/9/2009 4:54:38PM SAN JOA^TJIN COUNTY ENVIRONMENTAL HEALT"DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/9/200 <br /> Record Selection Criteria: Facility ID FA0013514 <br /> Make chaINFORMATI N C In RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION .�--- SSN/Fed Tax ID <br /> Owner ID OW0010643 New Owner ID <br /> Owner Name COLLICUT ENERGY SERVICES INC <br /> Owner DBA COLLICUT ENERGY SERVICES INC <br /> Owner Address 3955 E ARCH RD <br /> STOCKTON, CA 95215 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-462-1586 <br /> Mailing Address 940 RIVERSIDE PKWY STE 80 <br /> W SACRAMENTO, CA 956051513 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013514 <br /> Facility Name COLLICUT ENERGY SERVICES INC <br /> Location 396&E-ARCH Rp- 56Il 't-� <br /> STOCKTON, CA 95215 95b o S <br /> Phone 209-462-1586 <br /> Mailing Address <br /> STOGKTON, GA 9624-5 <br /> Care of LARA, SALLY <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 17926045 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 AR0022618 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name COLLICUT ENERGY SERVICES INC (Circle One) <br /> Account Balance as of 2/9/2009: $567.00 <br /> (Clyde One) <br /> Transferto Active/Inacive <br /> Progranv Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PRO517590 EE0008317-RAYMOND VON FLUE Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO517592 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PRO521153 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARIPR0517591 EE0000000-HAZ MAT SJC DES 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,PHSIEHD hourly charges associated with this <br /> facility or activity will be billed to Me parry 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. CC fin" (1 �� ���.1A <br /> APPLICANTS SIGNATURE: dQ� av�Cl r\ �"tv� �..d� rr°A""^'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 4 <br /> REHS: Date / I Account out: Date <br /> COMMENTS: <br /> \\eh-env\envisionVeports\5021.rpt <br />