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Date run 8/12/2010 10:40:52AI SP 'OUIN COUNTY ENVIRONMENTAL Hh C H DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/12/ N <br /> Record Selection Criteria: Facility ID FA0010595 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0008595 Case Number:A108379 New Owner ID <br /> Owner Name HOLT OF CA <br /> Owner DBA — <br /> Owner Address �7nc <br /> Home Phone Not Specified <br /> ork/Business Phone 2e9 6J Q-)Q 43 Ll — C' 3 <br /> Mailing Address T C 66/x '( <br /> SACRAMENTO, CA 958131306 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010595 <br /> Facility Name HOLT OF CA <br /> Location 1234 W CHARTER WAY <br /> STOCKTON, CA 952.06. <br /> Phone 209-944-55e6- Cf 2- <br /> Mailing <br /> Mailing Address PO BOX X <br /> SACRAMENTO, CA 958131306 <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> Ll J <br /> BOS District 001 -VILLAPUDUA Fax L(L/ <br /> APN 16320004 EMail : Q y t 'rLQ <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name a*' <br /> Title <br /> Day Phone <br /> Night Phone Z 120 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017595 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name HOLT OF CA (Circle One) <br /> Account Balance as of 8/12/2010: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0519075 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOtPRO512883 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPR0510595 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATI\PR0528303 EE0001421 -STACY RIVERA Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0523138 EE5555555-Garrett Alias-Backus Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PR0534208 Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility 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 Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: "$372.00= Amount Paid Date <br /> Payment Type Check Number Received ) <br /> RENS: U1f' El f Date ! �3 /_� Account out: Date /.1 <br /> COMMENTS: <br /> 01 T CJ-) el <br /> \\eh-env\envisio reports\ 021.rpt <br />