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Datemn ,3/21/2012 10:53:21AI SAN JIOUIN COUNTY ENVIRONMENTAL HEAhd&u DEPARTMENT Reporl#5021 <br /> Run by 1273 Pagel <br /> Facility Information as of 3/21/2 <br /> Record Selection Criteria: Facility ID FA0015465 <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 OW0000925 New Owner ID <br /> Owner Name STONE BROS AND ASSOCIATES <br /> Owner DBA <br /> Owner Address 5757 PACIFIC AVE STE 220 <br /> STOCKTON, CA 952075159 <br /> Home Phone 209-478-1791 <br /> Work/Business Phone Not Specified <br /> Mailing Address 5757 PACIFIC AVE STE 220 <br /> STOCKTON, CA 952075159 <br /> Care of STONE BROS <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0015465 <br /> Facility Name FORMR MONTGOMERY WARDS AUTO SR\ <br /> Location 5400-5606 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> Phone 209-478-1791 <br /> Mailing Address 1024 W ROBINHOOD DR#1 <br /> STOCKTON, CA 95207 <br /> Care of STONE BROTHERS <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002- RUHSTALLER, LARRY Fax <br /> APN 10227008 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name BEN HENINGBURG <br /> Title PROJECT MANAGER-ENSR <br /> Day Phone 916-362-7100 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0026684e � � 1 New Account ID: <br /> Mail Invoices to Account yl. � Mail Invoices to: Owner / Facility I Account <br /> Account Name AECOM P (Circle one) <br /> Account Balance as of 3/21/2012: $437.50 <br /> (Circle One) <br /> Transferto Active/lnactve <br /> Program/Element and Description Racer, ID Employee ID and Name Status New Owner? Delete <br /> 2957-UST FILE-RWQCB PRO522692 EE0000684-MICHAEL INFURNA Active Y N A 1 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 <br /> facility or activity,will be billed to the Parry identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANTS SIGNATURE: Date I / <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 Receive <br /> REHS: Date / / Account out: <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />