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Dai 9R4/2013 1:56:18PA SAN JOIN COUNTY ENVIRONMENTAL HEALRDEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 9/24/2013 Pagel <br /> Record Selection Criteria: Facility ID FA0004532 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0003440 New Owner ID <br /> Owner Name <br /> Owner DBA <br /> Owner Address 565- tFTIrAVEi <br /> Home Phone .Not Specified <br /> Work/Business Phone-qt4=6g4 l <br /> Mailing Address 6RL5 FI F:in-nwc4-L <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0004532 <br /> Facility Name KEARNEY NATIONAL (KEARNEY KPF) <br /> Location 1624 E ALPINE AVE <br /> STOCKTON, CA 95205 <br /> Phone 209-464-8381 <br /> Mailing Address 565 FIFTH AVE 4 FL <br /> NEW YORK, NY 100172424 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 11708006-09 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name HARRY MOSSBERGER <br /> Title <br /> Day Phone 209-464-8381 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0004273 New Account ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name KEARNEY NATIONAL (KEARNEY KPF) (Circle One) <br /> Account Balance as of 9/24/2013: $0.00 <br /> (Circle One) <br /> Program'Element to Activefitaclve <br /> Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2960-RWQCB SITE PR0009012 EE0000997-HARLIN KNOLL Active 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 facility <br /> or ai will be billed to the party identified as the OWNER on this forth 1 also certify that all operations will be performed in accordance with all applicable Ordinance Codes anclor Standards and State angor <br /> Federal I a". <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 /> Payri Type Check Number Received by <br /> E <br /> TS: Date <br /> COMMAccount out: ate / /3 <br /> COMME <br />