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Date run 9/20/2011 9:57:36AN SAN JO N COUNTY ENVIRONMENTAL HEAL jODEPARTMENT Report#5021 <br /> Run by 5290 Pagel <br /> Facility Information as of 9/20/20 <br /> Record Selection Criteria: Facility ID FA0010425 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) r ' <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0008425 Case Number: H08067 Ne Owner ID <br /> Owner Name PROACTIVE NORTHERN CONTAINER �021U tJ�? <br /> Owner DBA <br /> Owner Address 4343 E FREMONT ST 53D On <br /> STOCKTON, CA 95215 9alaiv , Cita 53.5 <br /> Home Phone 209-546-0111 Se b U 9"IT <br /> Work/Business Phone 2 W— O e) <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 209-546-0111RSp CJI '¢y! 3 400 DC�� <br /> Mailing Address 4343 E FREMONT ST c 465,9 E { z c*-YDYL- <br /> STOCKTON, CA 95215 Mn LgfD LI Ft 9535'7 <br /> Care of HARTOG, GARY <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax J 2 <br /> APN 14328039 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION lrhe� <br /> Contact Name JOEXODUCTION <br /> t1 <br /> Title PRINMGRDay Phone 209-Night Phone 209- xFAX � — IWO;z t <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 9/20/2011: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee IO and Name Status New Owner? Delete <br /> 2220-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 DES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-IDES PR0520340 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 SURCHARFIR0510425 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATAPR0529235 EE0009488-JEFFREY WONG Active,Exempt Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPR0533738 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 /> facilityor activity will be billed to the part'identified as the OWNER on this form. I Iso ceN that ail operations will be performed in accordance with all appligble ONinace Codes and/or Standards and <br /> Stale and/or Federal Laws. P <br /> V <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date / I <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Receivefl by, <br /> RENS: Date / / Account out: (�"�j Date / _V / 1 <br /> COMMENTS: %la � ta / <br /> I <br /> \\eh-env\envision\reports\5021.rpt ✓� / /// <br />