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Date run 8/3/2011 8:27:13AM SAN JOE IN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/3/2011 <br /> Record Selection Criteria: Facility ID FA0002805 <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 OW0002106 New Owner ID : <br /> Owner Name nnm,E, 'TZEF T G!S 9a,2.A /4ssr7 7r <br /> Owner DBA KAISER ROAD TRUST <br /> Owner Address 1680 INBIAN VALLEY RB / O <br /> CTY, cscc/ MN SS/Sy <br /> Home Phone - <br /> Work/Business Phone 800 303-8480- <br /> MailingAddress 1680 IN9I N pint r EY„v <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0002805 <br /> Facility Name •PG^RGE-iEFF r11r - <br /> 40 <br /> Location 5125 S KAISER RD <br /> STOCKTON, CA 95215 <br /> Phone <br /> Mailing Address 14680 INDIAN VALLEY RE) <br /> Care of-PE-ARGE 1EFF u_ <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 002- RUHSTALLER, LARRY Fax <br /> APN 18104006 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name .PEARGE iEFF EX ins <br /> Title <br /> Day Phone 416 91 2600 <br /> Night Phone.416-898 8062- <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002366 NewAccount ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name-P{pRG ,E 'tom;Tr (Circle One) <br /> Account Balance as of 8/3/2<ZI 459.50 <br /> \\ tqk (Circle One) <br /> N[ "fDJ Transfer to Active/Inactve <br /> Ow <br /> Program/Element and Description Record ID Employee I and Name Status New ner? Delete <br /> 2765-EMPLOYEE HOUSING-PERMANENT>180 D/PR0270040 EE0008987-SCOTT SANGALANG Active Y N A I D <br /> 4630-NTNC WATER SYSTEM WA0461354 EE0005838-ADRIENNE ELLSAESSEActive 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 <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 Ordinate Codes and/or Standards and <br /> State and/or 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 Ty a Check Number Recei y 1 / <br /> REHS: � at4987 Date 13 Account out: Date / <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />