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Datemn 1/26/2015 4:16:18PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Repon#5021 <br /> Paget <br /> Run by Facility Iriformatfon as of 1/26/2015 <br /> Record Selection Criteria: Facility ID FA0006423 <br /> Make c orrections in RED ink. <br /> INFORMATION CHA <br /> OWNERSHIP CHANGE( <br /> <br /> �— . <br /> Owner Name �tltQ' <br /> Owner DBA <br /> Owner Address <br /> l;6rA6T93'CA 94022 <br /> Home Phone 605-941-1852 <br /> Work/BusinessPhone 650-941-1852 <br /> Mailing Address 185 N EL MONTES P <br /> LOS AL A 94022 <br /> Care of L EAN HYUN <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID/CERS ID FA0006423 10182099 <br /> Facility Name UNITED GAS <br /> Location 3440 E MAIN ST <br /> STOCKTON, CA 95205 <br /> Phone 209-463-7716 x <br /> Mailing Address 3440 E MAIN ST <br /> STOCKTON, CA 95205 <br /> JCC <br /> Care of.,IFF: Ki;iwcaL1 <br /> 5 � <br /> Location Code 01 -STOCKTON Ah Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 15716002 EMail: %I d n <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION �/�{--� n C/ �( <br /> Contact Name JEAN HYUN LEEJ 7 Q- <br /> Title <br /> Day Phone 209-463-7716 <br /> Night Phone - <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0009105 /�, '_ a ew Account ID: <br /> Mail Invoices to Account Ivj(l41 Mail Invoices to: Owner Facility Acwunt <br /> Account Name UNITED GAS IN e1 <br /> Account Balance as of 1/26/2015: $2 0 0 / <br /> /G�p s (Circe One) <br /> "'h'jS/ Transfer to Ac[ive4nacNe <br /> Program0ement and Description Retard Employee ID and Name Status New Owner? Delete <br /> 1615-RETAIL MKT 301-2000 So FT(PREPKGD/LTD PRO161544 EE0008999-L NH Active Y N A I D <br /> 1920-HMBP-Common Materials SAEED Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR05185 0009488-JEFFREY WONG Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512638 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2301 -UST STATE SURCHARGE FEE PRO507753 EE0000008-LETITIA BRIGGS Inactive Y N A I D <br /> 2361 -UST FACILITY PR0231173 EE0009488-JEFFREY WONG Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PRO607625 EE0000008-LETITIA BRIGGS Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PRO518584 EE0001422-ARTS VELOSO Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0533195 Inactive Y N A I D <br /> BILLING am COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,andor protect specific,PHSEHD 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 ardor Standards and State andor <br /> Federal Laws. / _� / /l^ <br /> APPLICANTS SIGNATURE: 1 D ��`Iry Date <br /> Program Records to be SFERED: —*$25.00= Amount Paid Date <br /> Water System to b T NS ERED: Amount Paid Date <br /> Payment Type Check Number Receive by <br /> REHS: Date l I Account out: Date_I yDp' <br /> l r <br /> COMMENTS: <br />