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Date run 8/17/2015 1:36:08Ph SAN JOIN COUNTY ENVIRONMENTAL HEAq DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/17/2015 <br /> Record Selection Criteria: Facility to FA0014388 <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: 1 SSN/Fed Tax ID <br /> Owner ID OW0011430 New Owner ID <br /> Owner Name RANDEL BARCLAY <br /> Owner DBA BARCLAY MACHINE WORKS INC <br /> Owner Address 3164 LOOMIS AVE <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-969-2882 <br /> Mailing Address 3164 LOOMIS AVE <br /> STOCKTON, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0014388 10184619 <br /> Facility Name BARCLAY MACHINE WORKS INC <br /> Location 3164 LOOMIS AVE <br /> STOCKTON, CA 95205 <br /> Phone 209-466-1209 xO <br /> Mailing Address 3164 LOOMIS AVE <br /> STOCKTON, CA 95205 <br /> Care of Mark Diemunsch <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 17910009 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 AR0024468 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name BARCLAY MACHINE WORKS INC (Circle One) <br /> Account Balance as of 8/17/2015: $0.00 <br /> (Circle One) <br /> Transfer to Aclivennactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO519246 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532341 Inactivc Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identifietl as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> 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 Type Check Number Received by <br /> EHD Staff: Date / /_ Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />