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Date mn 12/15/2014 4:11:02P SAN JIN COUNTY ENVIRONMENTAL HEA10.DEPARTMENT <br /> Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/15/2014 <br /> Record Selection critena. Facility ID FA0009079 <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 OW0007079 Case Number: H00942 New Owner ID <br /> Owner Name EDWARD F FORTUNE <br /> Owner DBA ABC RADIATOR <br /> Owner Address 601 S WILSON WAY <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-463-7401 <br /> Mailing Address 601 S WILSON WAY <br /> STOCKTON, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0009079 10182393 <br /> Facility Name ABC RADIATOR <br /> Location 601 S WILSON WAY <br /> STOCKTON, CA 95205 <br /> Phone 209-463-7401 <br /> Mailing Address 601 S WILSON WAY <br /> STOCKTON, CA 95205 <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 15129606 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016079 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name ABC RADIATOR (CirdeOne) <br /> Account Balance as of 12/15/2014: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inal <br /> Program Element and Description Record ID Employee ID and Name Status New Owner! Delete <br /> 1921 -HMBP-Regular-Primary Location PR0519366 EE0000006-HAZA SAEED Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO513624 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511367 EE0000000-HAZ MAT SJC OES Inactivc Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO609079 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534369 Inactivc Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the untlersigned owner,operator or agent of same,acknowledge that all site,andor protect specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the Party identified as Ne OWNER on this form. I also minify Chet all operations will be performed in accordance with all applicable Ordinance Codes andfor 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 /> REHS: Date I_I Account out: Date <br /> COMMENTS: <br />