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Date run 12/6/2004 2:20:56PN SAN JOI '1N COUNTY ENVIRONMENTAL HEAI DEPARTMENT Report 95021 <br /> Run by <br /> --llay Information as of 12/6/2004 Pagel <br /> Record Selection Criteria: Facility ID FA0015126 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OWOO11004 New Owner ID <br /> Owner Name CALTRANS <br /> Owner DBA CALTRANS <br /> Owner Address 1976 W CHARTER WAY <br /> STOCKTON, CA 95205 <br /> Home Phone 209-468-3913 <br /> Work/Business Phone Not Specified <br /> Mailing Address 1976 W CHARTER WAY <br /> STOCKTON, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0015126 <br /> Facility Name CAL TRANS AREATED DEPOSIT LEAD SOIL <br /> Location HWY 99 <br /> STOCKTON, CA 95203 <br /> Phone 209-468-3913 <br /> Mailing Address 555 E WEBER AVE <br /> STOCKTON, CA 95202 <br /> Care of SAN JOAQUIN COUNCIL OF GOVERNM <br /> Location Code 01 - STOCKTON APN: <br /> BOS District SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0025950 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner 1 Facility ! Account <br /> Account Name SAN JOAQUIN COUNCIL OF GOVERNMENTS (CirdeOne) <br /> Account Balance as of 12/6/2004: <br /> $-55 <br /> ;Circle One} <br /> Transfer to Activehnactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PR0522185 EE0000684-MICHAEL INFURNA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSIEHD hourly charges associa 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 /> APPLICANrs SIGNATURE: Date I I <br /> Program Records to be TRANSFERED: "$20.00= Amount Paid Date / 1 <br /> Water Syste be TRANSFERED: "$155.00= Amount Paid Date 1 I <br /> Payment Tye Check Number Recei e <br /> RENS: Date I ! AccounE out: Date 1 I <br /> COMMENTS: or <br /> 11phs-ehsql-ntlappslenvisions\reportsk502l.rpt <br />