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Date rur4� 3/21/2013 9:36719AN SAN JUIN COUNTY ENVIRONMENTAL HEAD-DEPARTMENT Report#5021 <br /> Run Cjr" Pagel <br /> Facility Information as of 3121120 3 <br /> Record Selection Criteria: Facility ID FA0005008 <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 OW0003896 New Owner ID <br /> Owner Name 4aef--pAfftT-t" <br /> Owner DBA v-e- <br /> Owner Address 620 N SAN JUAN <br /> STOCKTON, CA 95203 <br /> Home Phone Not Specified r... <br /> Work/Business Phone j�4gg A4g$— rtr9 % 7� <br /> f. Mailing Address 620 SAN JUAN AVE <br /> STOCKTON, CA 95203 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID l CERS ID FA0005008 10,181,705 <br /> Facility Name R GI PA44� 1 <br /> Location 620 N SAN JUAN <br /> STOCKTON, CA 95203 <br /> Phone 25969.AQ $—x9 , _Mailing Address 620 SAN JUAN AVE <br /> STOCKTON, CA 95203 <br /> Care of <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> Al 13339001 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 AR0005451 New Account ID: <br /> Mail Invoices to Owner J� ^ g Mail Invoices to: Owner I Facility ! Account <br /> Account Name P /'� G�� ©s((CirclI One} <br /> Account Balance as of 3/21/2013: $724.50 - �dJ SLS © 9-® r - d . <br /> �4 J ZO 2- CV�tc �Circie One} <br /> 5 Transfer to Active/lnactve <br /> Program/Element and Descuptfen Rdrd't E ` Status New Owner? Delete <br /> 1 g21 -HMBP-Regular-Primary Location PRO527530 EE0009817-ROBERT LOPEZ ` Active Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1184)-obsolete PR0501168 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHiPR0533340 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: E,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PI-i 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 andlor Standards and State andror <br /> Federal Laws, <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: $25.00= Amount Paid Date I I <br /> Water System to be TRANSFERED: Amount Paid Date 1 / <br /> Payment Typ Check Number Receiyed by G <br /> REHS: Z-- Date 1 Z3 1"3 Accountout: Date I 1 <br /> COMMENTS: <br />