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Date run 5/21/2013 4:09:05PK SAN JC UIN COUNTY ENVIRONMENTAL HEAT t DEPARTMENT Report#5021 <br /> Run by <br /> Pagel <br /> Facility Information as of 5/21/20'13 <br /> Record Selection Criteria: Facility ID FA0020701 <br /> Make changes/corrections ink <br /> INFORMATION CHANGE(date) Z/ / <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0017010 N""'^"'""'In <br /> Owner Name Xmac.. :�a..� ✓Y%. <br /> Owner DBA l <br /> Owner Address ssET^^ ^^ ^Tc c <br /> �c c VC-AT <br /> Home Phone Not Specified <br /> Work/Business Phone 54g-2gg-5278 - -S-7 1 O O O <br /> Mailing Address I r' -A .(^( . <br /> Care of 7 o <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0020701 <br /> Facility Name <Q,MA:F$d1 y '� : r� <br /> Location 3Z3 MF RKf-V`i AY S }- - <br /> STOCKTON, CA 95215 <br /> Phone q{ <br /> Mailing Address 3734 IMPERIAL WAY �' h/ <br /> STOCKTON, CA 95215 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 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 AR0037118 NewAccount ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name (Circle One) <br /> Account Balance as of 5/21/2013: $O.00J/�- ar 0)7G�� X Z Ye? rs <br /> (Cil One) <br /> Transfer to Active4nactve <br /> PrograMElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO535942 Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO535958 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ander 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 cedify that all operations will be performed in accordance with all applicable Ordinance Codes ardor Standards and State ander <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / I <br /> Water System to be TRANSFERED: Amount Paid Date / I <br /> Payment Ty ---Check Number Receive y <br /> REHS: 1`eLoo Z Z Date, /_�`/1-'Z Account out: Date / /L <br /> COMMENT <br /> 20 ����1 ►� <br />