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Date nm 2/11/2009 9:55:31AM SAN JO/ AN COUNTY ENV!-_ ONM7 'JAL HEAT ' DEPARTMENT Report#5021 <br /> Runby i2JO <br /> Facility Information az,of 2/11/2009 Pagel <br /> Record Selector,Criteria: Facility 10 FA0010429 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0008429 Case Number: H08084 New OwnerlD <br /> Owner Name ANDREW SALMERON SR <br /> Owner DBA DOUBLE A TRUCK SVC <br /> Owner Address 1675 W CHARTER WAY <br /> STOCKTON, CA 95206 <br /> Home Phone Not Specified <br /> Work/Business Phone 925-634-5020 <br /> Mailing Address PO BOX 7310 Pig D j q-D 2— <br /> STOCKTON, <br /> STOCKTON, CA 95267 S L-A g14EZ5 - 7q-D2- <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010429 <br /> Facility Name DOUBLE A TRUCK SVC <br /> Location 1675 W CHARTER WAY D <br /> STOCKTON, CA 95206 <br /> Phone 209-467-0873 n <br /> Mailing Address PO BOX 7310 t'D D`, l q-D Z <br /> STOCKTON, CA 95267 �;S�o VfJu� A c / f LAY <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOIS District 001 - GUTIERREZ, STEVE Fax <br /> APN 163-370-10 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 AR0017429 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name DOUBLE A TRUCK SVC (Cbae0ne) <br /> Account Balance as of 2/11/2009: $522.00 <br /> (Circle One) <br /> Transfer to ActiveMawe <br /> PrograNElanent and Description Record ID Employee ID and Nene Status Now Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PRO514324 EE0008317-RAYMOND VON FLUE Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIONPRO512717 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PRO520314 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAROPR0510429 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,acknomedge that all site,aid/or project specific,PHSIEHD hourly charges associated w M this <br /> facility or activity will be billed to Me party idersified as me OWNER on this form. I also certify that all mansions x111 be performed in accordance with all applicable Ordin sce Codes aid/or Standards and <br /> Stale and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> W ate-System to be TRANSFERED: •$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> RENS: Date I / Account out: Date 4D <br /> COMMENTS: <br /> \\eh-env\emAsionkeports\5021.rpt <br />