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Date run 2/24/2011 3:17:31 PA SAN JUIN COUNTY ENVIRONMENTAL HE*DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/24/2011 <br /> Record Selection Criteria: Facility ID FA0015622 <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 OW0012568 New Owner ID <br /> Owner Name PEREZ,DAVI D/BALLESTEROS,GLORIA <br /> Owner DBA DSJ CUSTOM CABINETS INC <br /> Owner Address 1844 E TENTH ST <br /> STOCKTON, CA 95206 <br /> Home Phone 209463-4093 <br /> Work/Business Phone 209-547-1754 <br /> Mailing Address 1844 E TENTH ST <br /> STOCKTON, CA 95206 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0015622 <br /> Facility Name DSJ CUSTOM CABINETS INC <br /> Location 4843 E FREMONT <br /> STOCKTON, CA 95215 <br /> Phone 209-547-1754 <br /> Mailing Address 1844 E TENTH ST <br /> STOCKTON, CA 95206 <br /> Care of GLORIA BALLESTEROS <br /> Location Code 99-UNINCORPORATED A Alt Phone <br /> BOS District 002- RUHSTALLER, LARRY Fax <br /> APN 14328024 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name DAVID PEREZ <br /> Title <br /> Day Phone 209-547-1754 <br /> Night Phone 209-463-4093 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0026987 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name DSJ CUSTOM CABINETS INC (Circle One) <br /> Account Balance as of 2/24/2011: $262.00 <br /> (circle One) <br /> Transfer to ActwellnacNe <br /> Program/Element and Description Record ID Employee ID and Name Status New OwneO Delete <br /> 2220-SM HW GEN<5 TONS/YR PRO523134 EE0009488-JEFFREY WONG Active Y N AI D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPRO532755 Active Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific.PHSIEHD hourly charges associated with this <br /> facilityor 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 <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date / / <br /> Payment Type -heck Number Receiv 4 c— <br /> REHS: Date / / 'l 00 Accountout: Date a <br /> COMMENTS: -V1 T— ,,r� <br /> O i / ctrS�hQ.ss i/\. r y!y C C^.-'-D l V <br /> \\eh-env\envision\reports\5021.rpt <br />