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Date run 1/24/2013 2:30:32PR SAN JO AN COUNTY ENVIRONMENTAL HEAL 'DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 1/24/2013 <br /> Record Selection Criteria: Facility ID FA0005277 <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 OW0004132 New Owner ID <br /> Owner Name ANDERSON, JOHN B <br /> Owner DBA A W HAYES <br /> Owner Address 611 NORTH ST <br /> WOODLAND, CA 95695 <br /> Home Phone 530-666-2185 <br /> Work/Business Phone Not Specified <br /> Mailing Address 611 NORTH ST <br /> WOODLAND, CA 95695 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0005277 <br /> Facility Name A W HAYES <br /> Location 2005 NAVY DR <br /> STOCKTON, CA 95206 <br /> Phone <br /> Mailing Address 611 NORTH ST <br /> WOODLAND, CA 95695 <br /> Care of MAXIUM, PALOMA ANDERSON <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 16331010 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name MAXIUM, PALOMA ANDERSON <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0005737 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name PHEASANT INVESTMENT CORPORATION (Circle One) <br /> Account Balance as of 1/24/2013: $-375.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2332-EXEMPT TANK FACILITY PR0501944 EE0004636-GARRETT BACKUS Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0501941 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> 2957-UST FILE-RWQCB PR0535888 EE0000997-HARLIN KNOLL Active 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 facility <br /> 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 Ordinance Codes and/or Standards and State and/or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br />