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Date run 3/30/2011 3:42:17PR SAN JO'7UIN COUNTY ENVIILONMENTAL BEAT—H DEPARTMENT Report#5021 <br /> Run by _ Pagel <br /> Facility Information as of 3/30/201f <br /> Record selection Create; Facility ID FA0009046 <br /> Make cha INFslRMATION Cin RED ink. <br /> INFORMATION CHANGE(date) <br /> p Oc OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax 10 : <br /> Owner ID OW0007046 Case Number: H00623 New Owner ID <br /> Owner Name FRANK BROCKMAN <br /> Owner DBA CALIFORNIA RADIATOR WORKS <br /> Owner Address 328 S CALIFORNIA ST <br /> STOCKTON, CA 952033502 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-948-0746 <br /> Mailing Address PO BOX 159 <br /> MOUNTAIN RANCH, CA 952460159 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009046 <br /> Facility Name CALIFORNIA RADIATOR WORKS <br /> Location 328 S CALIFORNIA ST <br /> STOCKTON, CA 952033520 <br /> Phone 209-465-9118 <br /> Mailing Address PO BOX 159 <br /> MOUNTAIN RANCH, CA 952460159 <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 14909515 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name BRIAN DINGMAN <br /> Title MANAGER <br /> Day Phone 209-465-9118 <br /> Night Phone 209-464-0843 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016046 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility I Account <br /> Account Name CALIFORNIA RADIATOR WORKS Circle One) <br /> Account Balance as of 3/30/2011: $575.50 <br /> (circle Orel <br /> Transfer to Active/Inactve <br /> P ram/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 222 - HW GEN<5 TONS/YR PRO513606 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO511334 EE0000000-HAZ MAT SJC DES Inactive Y N A D <br /> 2226-CalARP PROGRAM PRO514519 EE000o000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PRO519345 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPRO509046 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPRO531459 Active Y N A 1 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge Nat all site,and/or project specific,PHS/EHD hourly charges associated weh this <br /> facility or activity,will be billed to the party identified as the OWNER on this form. I also certify Nat 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: Date <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type _ Ch Number Racalv <br /> REHS: Date /,5 / Account out: Date <br /> COMMENTS: <br /> \\eh-env\envislontr \5021.rpt <br />