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Date run 7/15/2013 3:31:26Ph SAN JO IN COUNTY ENVIRONMENTAL HEAIiDEPARTMENT Report#5021 Pagel <br /> Run by <br /> Facility Information as of 7/15/2013 <br /> Record Selection Criteria: Facility ID FA0004532 <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 OW0003440 New Owner ID <br /> Owner Name KEARNEY NATIONAL INC <br /> Owner DBA KEARNEY NATIONAL INC <br /> Owner Address 565 FIFTH AVE 4FL <br /> NEW YORK, NY 100172424 <br /> Home Phone Not Specified <br /> Work/Business Phone 914-694-6701 <br /> Mailing Address 565 FIFTH AVE 4FL <br /> NEW YORK, NY 100172424 <br /> Care of KEARNEY NATIONAL INC <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0004532 <br /> Facility Name KEARNEY NATIONAL (KEARNEY KPF) <br /> Location 1624 E ALPINE AVE <br /> STOCKTON, CA 95205 <br /> Phone 209464-8381 <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 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name HARRY MOSSBERGER <br /> Title <br /> Day Phone 209464-8381 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0004273 New Account ID: <br /> Mail lnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name KEARNEY NATIONAL(KEARNEY KPF) (Circle One) <br /> Account Balance as of 7/15/2013: $0.00 <br /> (Circle One) <br /> Transfer to ActiveMactve <br /> ProgrannElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 296 -RWQC13 SITE PR0009012 EE0000997-HARLIN KNOLL Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent ofsame,acknovdedge that all site,angor project specic,PHS/EHO hourly charges associated with this facility <br /> 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 Ordinance Caries andor Standards and State andor <br /> 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 Check Number Received by <br /> REHS: Date / / Account out: Date <br /> COM AENTS: <br /> �,� I11d� D� b <br />