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Date run 8/25/2008 3:20:23Ph SAN JO/ '►IN COUNTY ENVIRONMENTAL HEAL 'DEPARTMENT Report#5021 <br /> Run by 5290 % / Ne <br /> Pagel <br /> Facility Information as of 8/25/200 <br /> Record Selection Criteria: Facility ID FA0004075 <br /> Make changesicorrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN 1 Fed Tax ID <br /> Owner ID OW0002758 New Owner ID <br /> Owner Name PORT OF STOCKTON <br /> Owner DBA PORT OF STOCKTON <br /> Owner Address 2201 W WASHINGTON ST <br /> STOCKTON, CA 95203 <br /> Home Phone 209-946-0246 <br /> Work/Business Phone Not Specified WON <br /> Mailing Address PO BOX 2089 <br /> STOCKTON, CA 952012089 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0004075 <br /> Facility Name FORMER FALCON ENERGYIISC SITE <br /> Location #1 PORT RD 21 <br /> STOCKTON, CA 95203 <br /> Phone <br /> Mailing Address PO BOX 2089 <br /> STOCKTON, CA 95201 <br /> Care of RITA KOEHNEN <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -GUTIERREZ, STEVE Fax <br /> APN Entail <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name RITA KOEHNEN <br /> Title <br /> Day Phone 209-946-0246 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003735 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility / Account <br /> Account Name FORMER FALCON ENERGY/ISC SITE (Circle One) <br /> Account Balance as of 812512008: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? <br /> 2950-ENVIRON ASSESS PR0001237 EE0000684-MICHAEL INFURNA Acti Y N AW., <br /> D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,and/or roject spec.PHSlEHD hourty charges assoh 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 accord ce with all applicable Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 I <br /> Program Records to be TRANSF RED: `$20.00= Amount Paid Date / 1 <br /> Water System to be T SF ED: "$372.00= Amount Paid Date 1 ! <br /> Payment Type Check Number411 9Re ick v�d by <br /> REHS: Date I I Account out: e^ Date S 1'V0 ! <br /> COMMENTS: <br /> 11Ph s-ehsgl-ntla ppslenvisionslrepoftsk5021.rpt <br />