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Date run 2/10/2012 2:27:17PM SAN JC 'UIN COUNTY ENVIRONMENTAL HEP -H DEPARTMENT Report#5021 <br /> Run by 5290 Pagel <br /> Facility Information as of 2/10/22 <br /> Record Selection Criteria: Facility ID FA0019905 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax 10 <br /> Owner ID OW0008485 Case Number: H08203 New Owner ID : <br /> Owner Name HAROLD ALLEN <br /> Owner DBA <br /> Owner Address 2815 CHERRYLAND AVE <br /> STOCKTON, CA 95215 <br /> Home Phone 209-931-0333 <br /> Work/Business Phone 209-466-6555 <br /> Mailing Address PO BOX 5475 <br /> STOCKTON, CA 95215 <br /> Care of <br /> FACILITY FILE INFORMATION / <br /> Facility ID FA0019905 <br /> Facility Name REPORT RADIATOR <br /> Location 2815 CHERRYLAND AVE <br /> STOCKTON, CA 95215 <br /> Phone 209-931-0333 <br /> Mailing Address PO BOX 5475 <br /> STOCKTON, CA 95205 J <br /> Care of ALLEN, HAROLD <br /> Location Code 99- UNINCORPORATED it AN Phone <br /> BOIS District 002 - RUHSTALLER, LARRY Fax <br /> APN 08710065 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name HAROLD ALLEN <br /> Title <br /> Day Phone 209-931-0333 <br /> Night Phone 209-466-6555 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0035480 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name REPORT RADIATOR (Circle One) <br /> Account Balance as of 2/10/2012: $532.00 <br /> (Circle One) <br /> Transfer to ACbVe/InaLlve <br /> Program/Element and DescriptionRecord ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0530737 EE0004636-GARRETT BACKUS Active Y N A D <br /> 2244-PACT TRANSFER RECORD-DES PR0531234 Active Y N A D <br /> 3122-STORMW ATER INSPECTION-AUTO SHOP PRO530738 EE0004636-GARRETT B_A_CKUS Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH.PRO532331 -- Active Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,he undersigned owner,operator or agent of same,acknoWedge that all site,and/or project specific.PHS/EHD hourly charges associated wilt,his <br /> facility or acliNty will be billed to he parry identified as he OWNER on this form. 1 also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> Slate and/a 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 / I <br /> Payment Type Check Number Received <br /> RENS: i'_- Date�/ i.3 / —Account out: Date <br /> COMMENTS: <br /> b<�// -.{�, /P4rf5 <br /> -�/ x,17 �j � _1 � `i./I•V�L�h�� Il�rJG�InS fJ:,)1�- . <br /> Neh-envlenvlslon4epatsl5021.rp1 <br />