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un b�Date run 2/20/2014 2:49:05pp $AN J JIN COUNTY ENVIRONMENTAL HE DEPARTMENT <br /> Repan#5021 <br /> Facility Information as of 2/20/2014 Page' <br /> Record Selection Criteria: Facility ID FA0019950 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION \ OWNERSHIP CHANGE(date) <br /> Owner ID OW0016373 �I{r SSN/Fed Tax I: <br /> New Owner ID <br /> Owner Name ANDREW POLLINO ��yy% f <br /> Owner DBA p E /uMnvw irvtJ Ivy <br /> Address 9457 THORNTON RD <br /> STOCKTON, CA 95209 <br /> Home Phone Not Specified <br /> Work/Business Phone 2pg-4qq-8866 <br /> Mailing Address 2on�nRfLoo_AM_« f <br /> S ✓✓ t_ <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0019950 10187457 <br /> Facility Name p E <br /> Location 9457 THORNTON RD <br /> STOCKTON, CA 95209 <br /> Phone 21!091--�x0 <br /> Mailing Address 2 <br /> 9UTFURNTRAM—CT <br /> ST N, C <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> SOS District 003 - BESTOLARIDES Fax <br /> APN 08027001 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone - �,�/ �5 ' <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0035529 <br /> New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name ANBAEW—POLLING (Circle One) <br /> Account Ba ance as of 2/20/2014:`$348A0 41� � 1 A <br /> ��t (Circe One) <br /> Program/Element andbesuip0on Record ID Employee Ip and NameTransfer to Activennactve <br /> Status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO530794 EE0006044-LOWELL ALLEN Active Y N q p <br /> 2220-SM HW GEN<5 TONS/YR PR0538599 EE0004636-GARRETT BACKUS Active Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO534705 <br /> Inactive Y N A I GDD,,� <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I the undersigned owner,operator w agent of same,acknowledge that all site,and'or project specific,PHSrEHD hourly charges associated with this facile <br /> or activity wilt be billed to fine pally Identified as the OWNER on this form. I also wilily that all operations will be performed in accordance with all applicable Ortli once Codes andor Standards and State and/or <br /> Federal Laws. L pp <br /> � 977 2LZC ler �Lea..c `,,/� iv 0v---— +VeP — 9 —f <br /> F' Fo old o�M cr p lD t�=nla. c „� s�., 6,d ly'7- <br /> APPLICANT'S SIGNATURE: <br /> Program Records to be TRANSFERED: •$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: , Amount Paid Date <br /> _ <br /> Payment Type Check Number R c i by <br /> RENS: Date / '1/ �<--� Account out: Date_ <br /> COMMENTS: —T" <br /> FEB 2 8 2014 <br /> -7 yv -lz; � �, l L <br /> . � <br />