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Date run 3/3/2011 2:41:48PM SAN JOSN COUNTY ENVIRONMENTAL HEAEPARTMENT Report#5021 <br /> Run by Pagel <br /> . - Facility Information as of 3/3/201 <br /> Record Selection Criteria: Facility ID FA0013996 <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 OW0011075 New Owner ID : <br /> Owner Name Aef" +RETAIL Ctoo Qwa �c 1 o V :oeS <br /> Owner DBA \04-F <br /> Owner Address 46g2- uorFo oT +inn 00 S <br /> DENVER,GG 802- 1 o re\a VnA f r o 4tD E.319 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified 01ilb - 600S 330b <br /> Mailing Address q av-Q- <br /> DEN r� <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013996 <br /> Facility Name \AtFCTFRNFARkA CCD resC-(Do `f0 lr_,.r,c bv� 2fV:.•i 6c. y 0S If{ <br /> Location 1905 N BROADWAY <br /> STOCKTON, CA 95205 <br /> Phone <br /> Mailing Address RCLSOX-528 <br /> 6 uD nRc a.. vw sS <br /> Care of 5-LL\lii \\, {, <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District Fax <br /> APN 14315004 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0023683 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name CA .e\.'br'9— (Circle One) <br /> Account Balance as of 3/3/2011: $0.00 <br /> (Circle One) <br /> Transfer to Active/lnacive <br /> Program/Element and Description Record ID Employee ID and Name Status Nev,Omer? Delete <br /> 2960-RWQCB SITE PRO518600 EE0000684-MICHAEL INFURNA Acfive 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 hourlycharges 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 anwor Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSF ED: '$25.00= Amount Paid Date <br /> Water System to be TR S D: Amount Paid Date <br /> Payment Type eck Number Received by <br /> REHS: Date_ / / Account out: _ Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />