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Date run 7/26/2004 10:10:46AI SAN JUIN COUNTY ENVIRONMENTAL HE JH DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 7/26/2 4 <br /> Record Selection Criteria: Facility ID FA0009294 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0007294 Case Number: H02912 New Owner ID <br /> Owner Name ALPINE PACKING CO <br /> Owner DBA ALPINE PACKING CO INC <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-477-2691 <br /> Mailing Address PO BOX 691358 <br /> STOCKTON, CA 952691358 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009294 <br /> Facility Name ALPINE PACKING CO INC <br /> Location 9900 LOWER SACRAMENTO RD <br /> STOCKTON, CA 95210 <br /> Phone 209-477-2691 <br /> Mailing Address PO BOX 691358 <br /> STOCKTON, CA 952691358 <br /> Care of <br /> Location Code APN 084-080-01 <br /> BOS District SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016294 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name ALPINE PACKING CO INC (Circle One) <br /> Account Balance as of 7/26/2004: $15.00 <br /> (Circle One) <br /> Transfer to Active/InecNe <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner Delete <br /> 2214-CaIARP FAC STATE SURCHARGE FEE PRO518931 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2220-SM HW GEN<5 TONSNR PR0513755 EE0003580-MICHELLE LE Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0511582 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2226-CaIARP PROGRAM PR0514554 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PR0519523 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84) PR0500484 EE0000451 -STEVE SASSON Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPRO509294 EE0000000-HAZ MAT SJC DES Inactive Y N A 1 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project speck,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 andlor 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 <br /> COMMENTS: <br /> \\Phs-ehsq I-nt\apps\Envisions\Reports\5021.rpt <br />