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Date run 10/18/2016 4:00:32F SAN JOA&N COUNTY ENVIRONMENTAL HEALWEPARTMENT Report#5021 <br /> Run byPagel <br /> Facility Information as of 10/18/2016 <br /> Record Selection Criteria: Facility I D FA0018695 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID : <br /> Owner ID OW0015362 New Owner ID <br /> Owner Name <br /> Owner DBA ROBINHOOD PLAZA SHOPPING CENTE <br /> Owner Address 1036 ROBINHOOD DR 202 <br /> STOCKTON, CA 95207 <br /> Home Phone 209-478-1791 <br /> Work/Business Phone Not Specified <br /> Mailing Address 1036 ROBINHOOD DR STE 202 <br /> STOCKTON, CA 952075159 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID I CERS ID FA0018695 <br /> Facility Name ROBINHOOD PLAZA/1-HR MARTINIZING <br /> Location 5756 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> Phone 209-478-1791 <br /> Mailing Address 1036 ROBINHOOD DR STE 202 <br /> STOCKTON, CA 952075159 <br /> Care of SURREYLTD <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002 -MILLER, KATHERINE Fax <br /> APN 10227010 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SURREY LTD �Gf YA �{�1$y YlelKo / <br /> Title <br /> Day Phone 209-478-1791 =O I&Drn ZA V51i <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0033154 New Account 10: <br /> Maillnvoicesto Account Mail Invoices to: Owner / Facility / Account <br /> Account Name ROBINHOOD PLAZA/1-HR MARTINIZING (Circle One) <br /> Account Balance as of 10/18/2016 $0.00 <br /> (Circle One) <br /> Transfer to Active/InacNe <br /> Progra"Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2960-RWQCB LEAD AGENCY CLEAN UP SITE PRO527591 EE0001453-NUEL HENDERSON Active Y N A I 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 thisfacility <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 slate 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 /> EHD Staff: Date_/_/_ Account out: Date— /0 /-1 b <br /> COMMENTS: Invoice#: <br />