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Date run 9/2/2009 3:17:53PM SAN JUIN COUNTY ENVIRONMENTAL HE DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 9/2/2 <br />Record Selection Crilena: Facility ID FA0011023 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0007393 Case Number: H03711 <br />Owner Name <br />MORGANSON, DAVE <br />Owner DBA <br />INTERSTATE TRUC CENTER <br />Owner Address <br />3812 MONDRIAN DR <br />Phone <br />MODESTO, CA 953562448 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-678-0039 <br />Mailing Address <br />PO BOX 6463 <br />Location Code <br />STOCKTON, CA 95206 <br />Care of <br />COSLETT, RICK <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0011023 <br />Facility Name <br />INTERSTATE TRUCK CTR - COLLISION DI <br />Location <br />641 S HARRISON ST <br />STOCKTON, CA 95206 <br />Phone <br />209-467-3561 <br />Mailing Address <br />PO BOX 6463 <br />HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO513311 <br />STOCKTON, CA 95206 <br />Care of <br />COSLETT, RICK <br />Location Code <br />EE0008317 - RAYMOND VON FLUE <br />BOS District <br />Y N A I D <br />APN <br />14704047 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0018023 <br />Mail Invoices to Facility <br />Account Name INTERSTATE TRUCK CTR - COLLISION DI <br />Account Balance as of 9/2/2009: $0.00 <br />Make changes/corrections in RED ink. Z <br />INFORMATION CHANGE (date) G <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />Entail : <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <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 Receiv. <br />REHS: .�, J '!� �.O''� Date /�_/( Account out: Date / /� <br />COMMENTr :` <br />\\eh-env\envision\reports\5021.rpt <br />(Circle One) <br />Transfer to Active/Inaclve <br />Program/Element and Description Record ID <br />Employee ID and Name <br />Status <br />New Owner7 Delete <br />HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO513311 <br />EE0000000 - HAZ MAT SJC DES <br />Inactive <br />Y N A I D <br />22 GEN 5<25 TONS PERMIT PRO514497 <br />EE0008317 - RAYMOND VON FLUE <br />Active <br />Y N A I D <br />2244 -PACT TRANSFER RECORD - DES PR0520616 <br />EE0000000-HAZ MAT SJC DES <br />Active <br />Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARPR0511023 <br />EE0000000 - HAZ MAT SJC DES <br />Inactive <br />Y N A I D <br />2840 -AST EXEMPT FAC <1,320 GAL PR0528799 <br />EE0008317-RAYMOND VON FLUE <br />Active,Exempt <br />Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknoWedge that all site, and/or project specific. PHS/EHD <br />hourly charges associated with this <br />facility or activity will be billed to the party Identified as the OWNER on this form. I also <br />certify that all operations will be performed in accordance with all applicable Ordinate Codes anNor Standards and <br />Slate andfor Federal Laws. <br />Plee� cIA P 2)7 Pee a a� �I <br />c ,mss <br />y� zoos, <br />APPLICANTS SIGNATURE: <br />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 Receiv. <br />REHS: .�, J '!� �.O''� Date /�_/( Account out: Date / /� <br />COMMENTr :` <br />\\eh-env\envision\reports\5021.rpt <br />