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Date run 8/25/2008 11:44:03AI SAN JUIN COUNTY ENVIRONMENTAL HEH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/25/2008 <br /> Record Selection Criteria: Facility ID FA0015622 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) 3-If-6S <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0012568 New Owner ID : n <br /> Owner Name .r,�r -"—" - t"16 Q�j/�2 -1 iYlA p0.(�05 elr•�y <br /> Owner DBA OS'C Cuckm cAlglimets aNc <br /> Owner Address <br /> Home Phone 209-892-746a y t{(,;- 443 <br /> Work/Business Phone 20q-46gg666 7-.011 S`47 <br /> Mailing Address _ IS" t�„ WIt- St- <br /> s s +nlm CA gs� <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0015622 <br /> Facility Name SS Cµ4 arr INeFc 2NG. <br /> Location 4843 E FREMONT <br /> STOCKTON, CAS <br /> Phone 209-469.6666. <br /> Mailing Address syr. <br /> r S TiN Gq <br /> A 6'�4(_ <br /> Care of <br /> Location Code 99- UNINCORPORATED A Alt Phone 94A tt-'14 -1961 <br /> BOS District 002- RUHSTALLER, LARRY Fax <br /> APN NO APN IN PV jLt-5-,;go 4 EMail: ANO 69 a cm%caA .N� <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name GARL"_ I•i-- C1(grjA DA STC�OS <br /> Title <br /> Day Phone 269#69-ee56- n AaLF _ rl 1 <br /> Night Phone _2QQ )g2_T3 3r— <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0026987 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name UNITED WOOD WORKS (Circle One) <br /> Account Balance as of 8/25/2008: $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 PRO523134 EE6666666-Toua Alias-Yang Inactive Y N A_1D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor 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 /> APPLICANTS 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 by <br /> REHS: Date 8 1W106 Account out: Date / / O(dr <br /> COMMENTS: <br /> �t_L.cfl �2xJyvl�� � 179103� <br /> \\phs-ehsgl-nt\apps\envisions\reports\5021.rpt <br />