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oaleM 9/15/2010 3:53:37PN SAN dO>AQUIN COUNTY ENVIRONMENTAL HEAT.TH DEPARTMENT Report°5021 <br /> RunesPagel <br /> A,— Facility Information as of 9/1S/2�' <br /> Record Selection Criteria: Facility ID FA0007087 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax to <br /> Owner ID OW0005820 New OwnerlD <br /> Owner Name BIG VALLEY FORD <br /> Owner DBA BIG VALLEY FORD <br /> Owner Address 3282 AUTO CENTER DR <br /> STOCKTON, CA 95212 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-473-1311 <br /> Mailing Address PO BOX 690398 <br /> STOCKTON, CA 95269 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0007087 <br /> Facility Name BIG VALLEY FORD <br /> Location 3282 AUTO CENTER CIR <br /> STOCKTON, CA 95212 <br /> Phone 209-956-5244 <br /> Mailing Address PO BOX 690398 <br /> STOCKTON, CA 95212 <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 003- BESTOLARIDES Fax <br /> APN 12802025 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 AR0010254 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner I Facility / Account <br /> Account Name BIG VALLEY FORD (circle One) <br /> Account Balance as of 9/15/2010: $0.00 <br /> (circle One) <br /> Transfer to AcEverinactve <br /> Program/Element and Description Record ID Employee ID and Name Stales New OwrleR Delete <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO511377 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> (�L22T-GEN 5<25 TONS PERMIT PR0505926 EE0004636-GARRETT BACKUS Active Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0519374 EE000oo00-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPR0507652 EE0004636-GARRETT BACKUS Inactive Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATI\PR0515782 EE0004636-GARRETT BACKUS Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO522793 EE0004680-NATALIA SUBBOTNIKO'Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PR0534221 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 hourty charges associated with this <br /> facility or wfivay will be billed to the party identified as the OWNER on this form. I also certfy that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> state and/or Federal Lars. <br /> APPLICANT'S SIGNATURE: Date if <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date I / <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type d Check Number Recall d <br /> REHS: Date_(2_/ �l L r7 Account out: Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rp[ 0— <br /> 44 <br />