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Date run 2/.17/2009 2:16:4OPh SAN JOIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> Run by 4006 Pagel <br /> Facility Information as of 2/17/20 <br /> Record Selection Criteria: Facility ID FA0011278 <br /> Make changes/corrections in RED ink or pe cit. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0009278 New Owner ID <br /> Owner Name AMBERLAND COMPOSITES LLC <br /> Owner DBA AMBERLAND COMPOSITES LLC <br /> Owner Address 3632 DUCK CREEK DR <br /> STOCKTON, CA 95215 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-460-1600 <br /> Mailing Address 3632 DUCK CREEK DR <br /> STOCKTON, CA 95215 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0011278 <br /> Facility Name AMBERLAND COMPOSITES LLC <br /> Location 3632 DUCK CREEK DR <br /> STOCKTON, CA 95215 <br /> Phone 209-460-1600 XO <br /> Mailing Address 3632 DUCK CREEK DR <br /> STOCKTON, CA 95215 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 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 AR0018278 NewAccount ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name AMBERLAND COMPOSITES LLC (Circle One) <br /> Account Balance as of 2/17/2009: $1,284.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> ProgaMElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2244-PACT TRANSFER RECORD-OES PRO513566 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARiPR0511278 EE0000000-HAZ MAT SJC OES Inactive 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 DatePaym <br /> REHSent Type Check Number n Re by Date <br /> a � Date—1--/ / Account out: <br /> COMMENirp <br /> TS: <br /> Sal P4 P u <br /> \\eh-env\envision\reports\5021.rpt <br />