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Date run 1/26/2015 4:16:18Pk SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility I6formatfon as of 1/26/2015 <br /> Record S.Ie ion Criteria: Facility ID FA0006423 <br /> Make C, i i i, n RED ink. <br /> INFORMATION CHANGE <br /> 1 124 <br /> OWNERSHIP CHANGE(date F <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed 32384' -V <br /> Owner ID OW0005463 New wryer ID <br /> Owner Name / 1(1614-1 <br /> Owner DBA <br /> Owner Address <br /> t4aA1465CA 94022 <br /> Home Phone 605-941-1852 <br /> Work/BusinessPhone 650-941-1852 <br /> Mailing Address 185 N EL MONTIE <br /> LOS AL , A 94022 <br /> Care of L 'AN HYUN <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID/CERS ID FA0006423 10182099 <br /> Facility Name UNITED GAS <br /> Location 3440 E MAIN ST <br /> STOCKTON, CA 95205 <br /> Phone 209-463-7716 x <br /> Mailing Address 3440 E MAIN ST <br /> STOCKTON, CA 95205 <br /> Care ofR- <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 15716002 EMail: G e v 't <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION //�� - r� m`r ' l02,71 <br /> Contact Name JE <br /> Title <br /> Day Phone 209-463-7716 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0009105 ewAccount ID: <br /> Mail Invoices to Account IUi� Mail Invoices to: Owner Facility Account <br /> Account Name UNITED GAS l� e> <br /> Account Balance as of 1/26/2015: $2 . 0 O r / �/� U <br /> / I / (Circe One) <br /> Transfer to /¢ti,mJlnadve <br /> Program/Element and Description Record Employee ID and Name Status New Owner? Delete <br /> 1615-RETAIL MKT 301-2000 So FT(PREPKGD/LTD PRO161544 EE0008999-L NH Active Y N A I D <br /> 1920-HMBP-Common Materials SAEED Active Y N A I D <br /> 2220-SM HW GEN<5 TONSNR PR05185 0009488-JEFFREY WONG Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO512638 EEo000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2301 -UST STATE SURCHARGE FEE PR0507753 EE0000008-LETITIA BRIGGS Inactive Y N A I D <br /> 2361 -UST FACILITY PR0231173 EE0009488-JEFFREY WONG Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PRO507625 EE0000008-LETITIA BRIGGS Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0518584 EE0001422-ARTS VELOSO Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0533195 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACRNOW-EDGEMENT: I,the undersigned awnee operator or agerd of same,acknowledge Nat all site,ardor project spednc.PHSAEHD hourly charges associated with mis faculty <br /> or activity will be billed to the party identfied as the OWNER on this form. I also oertdy,that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State and'or <br /> Federal Laws. (n <br /> APPLICANTS SIGNATURE: y I D ��L \ Date <br /> Program Records to be SFERED: "$25.00= Amount Paid Date <br /> Water System to b T NS EKED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date I / /a 1 Account out: V/✓ Date <br /> COMMENTS: <br />