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Date run 11/10/2009 3:04:03P SAN J IN COUNTY ENVIRONMENTAL HEA DEPARTMENT <br /> Report#5021 <br /> Run by Pagel <br /> Facility Information as of 11/10/2009 <br /> Record Selection Criteria Facility ID FA0010425 <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 1D OW0008425 Case Number: H08067 New Owner ID <br /> Owner Name PROACTIVE NORTHERN CONTAINER <br /> Owner DBA <br /> Owner Address 4343 E FREMONT ST <br /> STOCKTON, CA 95215 <br /> Home Phone 209-546-0111 <br /> Work/Business Phone Not Specified <br /> Mailing Address 4343 E FREMONT ST <br /> STOCKTON, CA 95215 <br /> Care of HARTOG, GARY <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0010425 <br /> Facility Name PROACTIVE NORTHERN CONTAINER <br /> Location 4343 E FREMONT ST <br /> STOCKTON, CA 95215 <br /> Phone 209-546-0111 <br /> Mailing Address 4343 E FREMONT ST <br /> STOCKTON, CA 95215 <br /> Care of HARTOG, GARY <br /> Location Code 99- UNINCORPORATED.4 Alt Phone <br /> BOS District 002- RUHSTALLER, LARRY Fax <br /> APN 14328039 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name JOE BILLETT <br /> Title PRINT PRODUCTION MGR <br /> Day Phone 209-546-0111 <br /> Night Phone 209-948-0142 xFAX <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017425 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name PROACTIVE NORTHERN CONTAINER (Circle One) <br /> Account Balance as of 11/10/2009: $0.00 <br /> (Circle one) <br /> 2 L-Z 74— Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner'! Delete <br /> -2228-SM HW GEN<5 TONS/YR PR0528554 EE0009488-JEFFREY WONG Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO512713 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2245-PACT TRANSFER RECORD-SUPPLEMENTPRO520340 Active Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0232095 EE0000451 -STEVE SASSON Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPR0510425 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATI\PRO529235 EE0009488-JEFFREY WONG 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 spec.PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the parry 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 Typ Che kNu ber Receive <br /> REHS: Date / / Account out: <br /> COMMEN <br /> o2Do <br /> \\eh-env\envision\reports\5021.rpt <br />