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Daterun + 8/21/2013 11:02:26AI SAN JO 'JIN COUNTY ENVIRONMENTAL HEA' I DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/21/2013 <br /> Record Selection Criteria: Facility ID FA0016231 <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 OW0013125 New Owner ID : <br /> Owner Name S,�— � �1•t/t 7�I A - �N✓�/,y�L <br /> Owner DBA <br /> Owner Address C <br /> Home Phone <br /> Work/Business Phone <br /> Mailing Address <br /> E;M=10 � <br /> Care of C <br /> FACILITY FILE INFORMATION �� <br /> Facility ID/CERS ID FA0016231 1�L�c-n�17k) <br /> Facility Name TY <br /> Location 1505 W NAVY DR <br /> STOCKTON, CA 95206 <br /> Phone <br /> Mailing Address PO X 838 ALV <br /> STO TO , CA 95208 <br /> Care of CHRIS PAS ESQ <br /> Location Code 01 - S KTON Alt Phone <br /> BOS District 001 ILL PUDUA Fax <br /> APN 16 0013 EMail: <br /> EMERGENCY NOTIFICATIO CO TACT I ORMATION <br /> Contact Name ICH RD AN <br /> Title NEIL A RSON &ASSOC GEOLOGIST <br /> Day Phone 209-36 701 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE NFORMA ION <br /> Account ID AR0028368 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name O (Circle One) <br /> Account Balance as of 8/21/2013: $-232.50 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PR0524159 EE0000997-HARLIN KNOLL 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 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 and/or <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 />