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Date run 9/9/2013 10:40:06AM SAN JC JIN COUNTY ENVIRONMENTAL HEA I DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9/9/2013 <br /> Record Selection Criteria: Facility ID FA0021921 <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 OW0008853 Case Number: H08879 New Owner ID <br /> Owner Name SAN JOAQUIN COUNTY PUBLIC WORKS <br /> Owner DBA <br /> Owner Address 1868 E HAZELTON AVE <br /> STOCKTON, CA 95205 <br /> Home Phone 209-468-3057 <br /> Work/Business Phone Not Specified <br /> Mailing Address 1868 E HAZELTON AVE <br /> STOCKTON, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0021921 <br /> Facility Name WILLIAMS TANKER SPILL <br /> Location 22754 E MARIPOSA RD <br /> ESCALON, CA 95320 <br /> Phone <br /> Mailing Address 1868 E HAZELTON AVE <br /> STOCKTON, CA 95205 <br /> Care of SJC PUBLIC WORKS <br /> Location Code 06- ESCALON Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN ROW EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SJC PUBLIC WORKS <br /> Title <br /> Day Phone 209-468-3057 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0039943 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name APEX ENVIROTECH INC (CirdeOne) <br /> Account Balance as of 9/9/2013: $-875.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Prograrn/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PR0537973 EE0001699-JOHNNY YOAKUM Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor 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 anclor <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 />