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Record Selection Chiantis. ENvIRO <br /> Facility IL) <br /> sANJO IN COUNTY <br /> FA0021725 FacilitYlnfor oraNMENTALHEAL` <br /> tion as of 7/18/2013 DEPARTMENT <br /> Rep-q#5021 <br /> Pagel <br /> OWNER FILE INFORMATION Make changesrcorrections in <br /> n RED ink. <br /> Owner ID N CHANGE(date) <br /> Owner OW0000482 OWNERSHIP <br /> Name SJC PUBLIC WO SSN/Fed Tax ID : CHANGE(data) - <br /> owner DBq SJC PUBLIC WORKS New Owner ID :Owner Address 1810 E HAZELTON AVE E <br /> Home Phone 2093031 95205 <br /> Wo"usiness Phone 209-948-1345 <br /> Mailinggddress PO BOX 1810 <br /> STOCKTON, CA 95201 <br /> Care of GORTON, DAVID <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERSID FA0021725 <br /> Facility Name SJCPW-BENJAMIN HOLT <br /> Location BENJAMIN HOLT DR <br /> STOCKTON. CA 95207 <br /> Phone 209-468-3541 <br /> Mailing Address PO BOX 1810 <br /> STOCKTON,CA 95205 <br /> Care of <br /> Location Code <br /> t Phone <br /> BOS District Al <br /> Fax <br /> APN EMail <br /> EMERGENCY NOTIFICATION CONTACT INFORNATON <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0039454 <br /> Mail Invoices to FacilityNew Account ID: <br /> Account Name SJCPW- BENJAMIN LT Mail Invoices to: Owner / Facility / Account <br /> Account Balance as of 7/18/2013: $-62.50 (Circle One) <br /> ProgramlElement and Description RID Employee ID and Name (circle One) <br /> P17701 EE0001699-JOHNNY YOAKUM Status Transfer r ActiDeleteve <br /> New Owner? Delete <br /> 2950-ENVIRON ASSESS Active Y N A <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,Neundersignedownepeoragentofsame,ackn0wled9e that all site, l anNor roectspecific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the parry identifed as the OWNER on this form I also Cat all operations will be pertormetl in accordance with allapplicable Ordinance Codes anNor Standards and Stale ander <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: $25.0 Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid <br /> Payment Type Check Number Date <br /> Received by <br /> REHS: Date / Account out: <br /> COMMENTS: � Date�/ / <br />