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gate nm •9/8/2009 10:15:14AM SAN JC JUIN COUNTY ENVIRONMENTAL HEA'" H DEPARTMENT Repw#5021 <br /> Paget <br /> Run by <br /> Facility Information as of 9/8/2 <br /> Record Selection Criteria. Facility ID FA0010485 <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 OW0008485 Case Number: H08203 New Owner ID : <br /> Owner Name HAROLD ALLEN <br /> Owner DBA REPORT RADIATOR <br /> Owner Address 2817 CHERRYLAND AVE �1:1",P 1 j L A n�n <br /> STOCKTON, CA 95215 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-466-6555 <br /> Mailing Address PO BOX 5475 J Z <br /> STOCKTON, CA 95215 <br /> Care of <br /> FACILITY FILE INFORMATION ,FAA9P7 90� <br /> Facility ID FA0010485 <br /> Facility Name REPORT RADIATOR <br /> Location 2817 CHERRYLAND AVE 13 <br /> STOCKTON, CA 95215 <br /> Phone 209-931-0333 <br /> Mailing Address 2817 CHERRYLAND AVE#13 <br /> STOCKTON, CA 95215 <br /> Care of <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 002-RUHSTALLER, LARRY Fax <br /> APN 037-100-65 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION , ) / <br /> Contact Name /7¢)i�'D 1, <br /> Title W/V <br /> Day Phone <br /> Night Phone o�j. L z,L <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017485 IT ti7/1��� 77S New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name HAROLD ALLEN (Circle One) <br /> Account Balance as of 9/8/2009: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0514349 EE0004636-GARRETT BACKUS Inactive Y N I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO512773 EE0000000-HAZ MAT SJC DES Inactive Y N h I D <br /> 2244-PACT TRANSFER RECORD-DES PR0520379 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPRO510485 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 3122-STORMWATER INSPECTION-AUTO SHOP PRO522964 EE0004636-GARRETT BACKUS Inactive Y N 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 with this <br /> facility or activity will be billed to the 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. / <br /> APPLICANT'S SIGNATURE: �'"' Date 02-12;—/i9 <br /> ) / ^�Qj <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date I / <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date / I <br /> Payment Type Check Number Racalv <br /> REHS: -o Date Account out/:: �Date_tel <br /> COMMENTS' <br /> s� r A✓c� <br /> \\eh-env\envision\reports\5021.rpt '3 j y y <br />