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Date ren 6/15/2010 12:52:50PI SAN JOA COUNTY ENVIRONMENTAL HEAL EPARTMENT <br /> Report#5021 <br /> Run by Pagel <br /> Facility Information as of 6/15/2010 <br /> Record Selection Criteria: Facility ID FA0018662 <br /> � Make changes/corrections in RED ink. <br /> = <br /> � INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION —..r„ SSN/Fed Tax ID <br /> Owner ID OW0000482 New Owner ID <br /> Owner Name SJC PUBLIC WORKS <br /> Owner DBA <br /> Owner Address 1810 E HAZELTON AVE <br /> STOCKTON, CA 95205 <br /> Home Phone 209-468-3031 <br /> Work/Business Phone 209-948-1345 <br /> Mailing Address 222 E WEBER AVE 6TH FL <br /> STOCKTON, CA 95202 <br /> Care of PUBLIC WORKS <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0018662 e S <br /> Facility Name S4G-Ptff3tfe-VV0TZKS - 'P_t,lkrti ¢iurnNa—lli[n., <br /> Location J.twC Pfn- <br /> Za°I - RSA- 9 'A'k <br /> Phone <br /> Mailing Address __4@= _ ,=_. __.. j�0 yVv'✓�L <br /> S419a4LJV e_ 'A 5Z�� <br /> Care of 11AIII C.A I�a tAaw. <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BIDS District 004-VOGEL, KEN Fax <br /> APN NONE 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 AR0033038 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility I Account <br /> Account Name KLEINFELDERINC (Circle one) <br /> Account Balance as of 6/15/2010: $0.00 <br /> (Cirde One) <br /> Transfer to AcWe/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PRO527550 EE0003611 -FRANK GIRARDI Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party identilied 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 andior Federal Laws. <br /> APPLICANTS SIGNATURE: / \..Ml�— Date J <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: *$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: �s� Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />