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Date run 12/6/2021 9:22:03AN 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 FA0024342 <br />Make changesicorrections 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 <br />OW0022884 New Owner ID <br />Owner Name <br />CALIFORNIA DEPT OF CORRECTIONS AND <br />Owner DBA <br />OwnerAddress <br />9838B OLD PLACERVILLE RD <br />SACRAMENTO, CA 95827 <br />Work/Business Phone <br />Not Specified <br />Alternative Phone <br />916-255-3359 <br />Mailing Address <br />9838B OLD PLACERVILLE RD <br />SACRAMENTO, CA 95827 <br />Care of <br />FACILITY FILE INFORMATION APN 23912001 <br />Facility ID/CERS ID <br />FA0024342 <br />Facility Name <br />DEUEL VOCATIONAL INSTITUTE <br />Location <br />23500 KASSON RD <br />TRACY, CA 95304 <br />Phone <br />916-255-3359 <br />Mailing Address <br />98388 OLD PLACERVILLE RD <br />SACRAMENTO, CA 95827 <br />Care of <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0045338 <br />Mail Invoices to Account <br />Account Name AECOM <br />New Acco u nt I D: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />Email invoice to (up to 2 emails) <br />Email permit to (up to 2 emails) <br />Account Balance as of 12/6/2021: $0.00 <br />(Circle One) <br />Transfer to Acti actve <br />Program/Element and Description Record ID Employee ID and Name Status New Owneo De <br />2960 - RWQCB LEAD AGENCY CLEAN UP SITE PR0542366 EE0000418 - MICHAEL KITH Active Y N 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 wit s facility <br />or activity will be billed to the party identified as the OWNER9n 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. // u <br />APPLICANT'S SIGNATURE: " A �I /fn/V Date 1 �4 6/ ?—It <br />Program Records to be TRANSFER <br />Water System to be TRANSFERED: <br />Payment Type <br />EHD Staff: <br />COMMENTS <br />Check Number <br />Irl <br />= rlrlvrft� It� Date ! / <br />Amou Paid Date <br />Received / <br />Date / ! Account out: Date <br />Invoice ##: <br />