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Date run I W29/2007 4:27:29P SAN JOAN COUNTY ENVIRONMENTAL HEAL EPARTMENT Report#5021 <br /> Run by 4006 Pagel <br /> Facility Information as of 10/29120 <br /> Record Selection Criteria: Facility ID FA0004032 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0002967 New Owner ID <br /> Owner Name LAZARES, DAVID <br /> Owner DBA AMER MOULDING & MILLWORK(FRMR) <br /> Owner Address <br /> Home Phone 408-3994393 <br /> Work/Business Phone Not Specified <br /> Mailing Address 634 N SANTA CRUZ AVE STE 100 <br /> LOS GATOS, CA 95030 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0004032 Site Mitigation Facility <br /> Facility Name AMERICAN MOULDING & MILLWORK (FIRM Site Mitigation Facility <br /> Location 2801 WEST LN <br /> STOCKTON, CA 95204 <br /> Phone 209-946-5880 <br /> Mailing Address 2801 WEST LANE <br /> STOCKTON, CA 95208 AA-j T 7E <br /> Care of MILL CREEK DEVELOPMENT-WEST LN C*-- t C4�Cac�� <br /> Location Code gg_ UNINCORPORATED AREA APN:11709001 <br /> BOIS District 002- RUHSTALLER, LARRY SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003672 New Account ID: <br /> Mail Invoices to Account Mail Invoices o: Owner / Facility / Account <br /> Account Name MILL CREE DEVELOPMENT (CirdeOne) <br /> Account Balance as of 10/29/2007: $98.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2951 -UGT-CAP PR0504943 EE0000756-CAROL OZ Inactive Y N A I D <br /> 2953-LCL HW CLEANUP SITE PRO505272 EE0000756-CAROL OZ Inactive Y N A I D <br /> 2959-DTSC- HW SITE PR0009016 EE0003611 -FRANK GIRARDI 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 rmjw specific,PHS/EHD hourly charges associated vrith this <br /> facility or activity will be billed to the party identified as the OWNER on this form. Il also certify that all operations will be performed in accardanc a with all applicable Ordinates Codes and/or Standards and <br /> Stale and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: �T Date -AL-2f/02 <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date / <br /> Payment Type Check Number Received by —7 <br /> REHS: Date / ! Account out: t� n ' Date /''l / / D <br /> COMMENTS: E%jED <br /> UCS 2 9 <br /> 201 <br /> ENPERM���ERVICES H <br /> \\phs-ehsq I-nt\apps\envisions\reports\5021.rpt <br />