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Date run 4/2/2009 10:28:57AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report*5021 <br /> Run by Pagel <br /> Facility Information as of 4/2/2009 <br /> Record Selection Criteria: FacilityID FA0007086 <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 OW0005819 New Owner ID <br /> Owner Name USG INTERIORS <br /> Owner DBA USG INTERIORS INC (LOOMIS) <br /> Owner Address 2575 E LOOMIS <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone 312-606-4000 <br /> Mailing Address 2575 E LOOMIS RD <br /> STOCKTON, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0007086 <br /> Facility Name USG INTERIORS <br /> Location 2575 E LOOMIS RD <br /> STOCKTON, CA 95205 <br /> Phone 209-466-4636 <br /> Mailing Address 2575 E LOOMIS RD <br /> STOCKTON, CA 95205 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Arc Phone <br /> BOS District 001 -GUTIERREZ, STEVE Fax <br /> APN 17911018 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0010253 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name USG INTERIORS (Circle One) <br /> Account Balance as of 4/2/2009: $0.00 <br /> (Circle One) <br /> Transferto Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name status New OwneR Delete <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO512006 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2227-GEN 5<25 TONS PERMIT PRO505925 EE0008317-RAYMOND VON FLUE Active Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PRO519821 EEOOO0000-HAZ MAT SJC DES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPR0507651 EE0000008-LETITIA BRIGGS Inactive Y N AD <br /> 3122-STORMWATER INSPECTION-AUTO SHOP PR0522971 EE0008317-RAYMOND VON FLUE Active Y N A I D <br /> a <br /> te with <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project spec,PHS/EHD hourly charges associ 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 accordance with all applicable Ordinace Codes and/or Stand ds and <br /> Stale and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date / "".� <br /> Water System to be TRANSFERED: *$372.00= Amount Paid Date t� �J <br /> X <br /> Payment Type Check Number Receiv S- <br /> ddt( " ' <br /> S Date L) /�/ Account out: Date <br /> COMM / / C,�•� <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />