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Date run 2/25/2015 10:43:27AI SAN JUIN COUNTY ENVIRONMENTAL HEA I DEPARTMENT Report 415021 <br /> Run by `.-, Pagel <br /> Facility Information as of 2/25/2015 <br /> Record Selection Criteria: Facility ID FA0003700 <br /> Make changes/corrections In RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 86 SSN/Fed Tax ID <br /> Owner ID OW0001176 New Owner ID <br /> Owner Name CITY OF STOCKTON <br /> Owner DBA <br /> Owner Address 425 N EL DORADO ST <br /> STOCKTON, CA 95202 <br /> Home Phone 209-937-8212 <br /> Work/Business Phone 209-937-8341 <br /> Mailing Address 425 N EL DORADO ST <br /> STOCKTON, CA 95202 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility lD/CERS ID FA0003700 10181321 <br /> Facility Name CITY OF STOCKTON FIRE STATION#3 <br /> Location 1116 E FIRST ST <br /> STOCKTON, CA 95206 <br /> Phone 209-937-8801 x <br /> Mailing Address 1116 E FIRST ST <br /> STOCKTON, CA 95206 <br /> Care of STOCKTON FIRE STATION#3 <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOB District Fax <br /> APN 16903006 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003278 New Account ID: <br /> Mall Invoices to Account Mail Invoices to. Owner / Facility / Account <br /> Account Name CITY T D ARTMENT cicaona> <br /> Account Balance as of 2/25/2015: 150.0 <br /> (Circle One) <br /> Transfer to Active racNe <br /> ProgramlElement and Description rd ID Employee ID and Name Sta law Ovme(! Delete <br /> 1920-HMBP-Common Materials PR0539630 EE0009817-ROBERT LOPEZ Ac ,I Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO511692 EED000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0231100 EE0000008-LETITIA BRIGGS Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0509404 EEo000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0528822 EE0000005-FATINAH ZAREEF Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge Nat all site,andor 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 wi l l be performed in accordance with all applicable Ordinance Codes andor Standards and State ander <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received b <br /> REHS: rm� Dated/—.?.7—/_Lr Acwunt out: Date / / �S <br /> COMMENTS: <br /> �J-ate �C-4sI--, 4, 6,i�r°� <br />