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Dare run 10/13/2011 1:57:44P SAN J"*,.QUIN COUNTY ENVIRONMENTAL HE,'- Report#5021 TH DEPARTMENT Pagel <br /> Pon by <br /> 10-- Facility Information as of 10/13I2Q'fN <br /> Record Selection Criteria: Facility ID FA0010511 <br /> 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 OW0008511 Case Number: H08246 New Owner ID <br /> Owner Name UNIV OF THE PACIFIC- PHARMACY <br /> Owner DBA <br /> Owner Address 3601 PACIFIC AVE <br /> STOCKTON, CA 95211 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-946-2222 <br /> Mailing Address 3601 PACIFIC AVE <br /> STOCKTON, CA 95211 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010511 <br /> Facility Name UNIV OF THE PACIFIC- PHARMACY <br /> Location 751 W BROOKSIDE RD <br /> STOCKTON, CA 95211 <br /> Phone 209-946-2222 <br /> Mailing Address 3601 PACIFIC AVE <br /> STOCKTON, CA 95211 <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002- RUHSTALLER, LARRY Fax <br /> APN 113-140-06 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 AR0017511 New Account to: <br /> Mail lnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name UNIV OF THE PACIFIC-PHARMACY (Circle One) <br /> Account Balance as of 10/13/2011: $0.00 <br /> (Circle Ona) <br /> Transfer to Active/Inactva <br /> Program/Element and Description Record IO Employee ID and Ni me Slalus New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0514359 EE0004636-GARRETT BACKUS Active Y N A D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO512799 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2226-CalARP PROGRAM PR0514795 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0520392 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARFIR0510511 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 4530-LG QUANITY GENERATOR PR0536181 EE0002620-ALFONSO ARAMBULA Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPRO531639 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 specific,PHS/EHD hourly charges associated wkh this <br /> facility or activity Will be billed to the party idenfified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinate Codes andlor Standards and <br /> State anNor 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 Recei y <br /> REHS: Date�/_ / _ Account out: Date 11L <br /> COMMENTS: <br /> \\eh-env\envisionUeports\sozl.rpt <br /> .wall �, ly� 1•^�:�r:Pv_ -fc„s ��;�•l,+r.. p/Lr,5f3`dj;S <br />