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Date run 12/6/2021 9:57:54AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 12/6/2021 <br />Record Selection Criteria: Facility ID FA0016571 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0013426 <br />Owner Name <br />CA DEPT OF CORRECTIONS <br />Owner DBA <br />DEUEL VOCATIONAL INSTITUTE <br />OwnerAddress <br />23500 KASSON RD <br />TRACY, CA 953049518 <br />Work/Business Phone <br />Not Specified <br />Alternative Phone <br />209-835-4141 <br />Mailing Address <br />23500 KASSON RD <br />TRACY, CA 953049518 <br />Care of <br />FACILITY FILE INFORMATION APN 23912001 <br />Facility ID / CERS ID FA0016571 <br />Facility Name DEUEL VOCATIONAL INSTITUTE <br />Location 23500 KASSON RD <br />TRACY, CA 953049518 <br />Phone 209-835-4141 <br />Mailing Address 23500 KASSON RD <br />TRACY, CA 953049518 <br />Care of CA DEPT OF CORRECTIONS <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name CA DEPT OF CORRECTIONS <br />Title <br />Day Phone 209-835-4141 <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Make changestcorrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Account ID AR0029225 New Account ID: : <br />Mail Invoices to ACCOUnt Mail Invoices to: Owner / Facility / Account <br />Account Name WOOD ENVIRONMENT & INFRASTRUCTURE SOL (Circle One) <br />Email invoice to (up to 2 emails) <br />Email permit to (up to 2 emails) S__p_ <br />Account Balance as of 12/6/20(1:.:$-3:07.40 t� <br />Program/Element and Description Record ID —Employee ID and Name <br />2960 - RWOCB LEAD AGENCY CLEAN UP SITE <br />PR0524672 EE0001699 - JOHNNY YOAKUM <br />Transfer to <br />Status New Owner? <br />Active Y N <br />(Circle One) <br />Active/Inactve <br />Delete <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, ancl/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 andror Standards and State and/or <br />Federal Laws. / *+ PD <br />APPLICANT'S SIGNATURE: Date <br />Program Records to be TRANSFERED: * $25.00 = Aount Paid Date / ! <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Type Check Number Received <br />EHD Staff: Date / / Account out: 64116L Date <br />COMMENTS: <br />Ir1V01Ce #: <br />