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Date run 7/1/2010 2:26:13PM SAN JUIN COUNTY ENVIRONMENTAL HE H DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/1/2 <br /> Record Selection Criteria: Facility ID FA0014439 <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 OW0011481 New Owner ID <br /> Owner Name <br /> Owner DBA ME)L�l GE)E)bZ-- L r <br /> Owner Address 1668 EL PINAL DR <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone 2A9 463-7�g Z 09- -7 56 --7//.3 <br /> Mailing Address 1668 EL PINAL DR <br /> STOCKTON, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0014439 <br /> Facility Name meLL1 eeel=z txn-1 — <br /> Location 1668 EL PINAL DR <br /> STOCKTON, CA 95205 <br /> Phone - ?09 - -756,--7// 2 <br /> Mailing Address 1668 EL PINAL DR <br /> STOCKTON, CA 95205 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax /+ <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name t j"Clic'ma SGr't�P.�t 5{t✓i 1—_ <br /> Title <br /> Day Phone Zc,-? --756-7/1 :3 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0024519 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name BRYAN FREEMAN (Circle One) <br /> Account Balance as of 7/1/2010: $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 /> 2244-PACT TRANSFER RECORD-OES PR0519297 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PR0533138 Inactive 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 with this <br /> facility or activity will be billed to the party 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 <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: *$372.00= Amount Paid Date <br /> Payment Type Check Number Receiv <br /> REHS: Date /�_/' Account out: Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />