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Date run 9/22/2004 1 : 53 :40PN SAN Jk. .)UIN COUNTY ENVIRONMENTAL HEA . ,CH DEPARTMENT Report #5021 <br /> Run by Pagel <br /> Facility Information as of 9/22/2004 <br /> Record Selection Criteria: Facility ID FA0013353 <br /> Make changes/corrections in RED ink or pencil . <br /> INFORMATION CHANGE (date) <br /> OWNERSHIP CHANGE (date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0009826 New Owner ID <br /> Owner Name BURLINGTON NORTHERN SANTA FE <br /> Owner DBA <br /> Owner Address 740 CARNEGIE DR <br /> SAN BERNARDINO , CA 92480 <br /> Home Phone 909 -3864082 <br /> Work/Business Phone Not Specified <br /> Mailing Address 740 CARNEGIE DR <br /> SAN BERNARDINO , CA 92480 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013353 <br /> Facility Name BURLINGTON NORTHERN SANTA FE <br /> Location 6540 S AUSTIN RD <br /> STOCKTON , CA 95215 <br /> Phone 209460-6000 <br /> Mailing Address 740 E CARNEGIE DR <br /> SAN BERNARDINO , CA 92480 <br /> Care of BURLINGTON NORTHERN SANTA FE <br /> Location Code 99 - UNINCORPORATED AREA APN : <br /> BOS District 004 - SEIGLOCK , JACK SIC Code : <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0022193 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name BURLINGTON NORTHERN SANTA FE (Circle One) <br /> Account Balance as of 9/22/2004 : $0 . 00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4630 - NTNC WATER SYSTEM WA0515477 EE0005838 - ADRIENNE ELLSAESSEActive 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 <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 and/or Federal Laws . <br /> APPLICANT'S SIGNATURE : Date <br /> Program Records to be TRANSFERED : * $20 . 00 = Amount Paid Date <br /> Water System to be TRANSFERED : * $ 155 . 00 = Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS : Date / / Account out: Date / 1 <br /> COMMENTS: <br /> \\phs-e hsq I-nt\apps\envisi ons\reports\5021 . rpt <br />