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Date run 6/22/2011 1:56:38PN SAN JOAN COUNTY ENVIRONMENTAL HEAL*EPARTMENT Report#5021 <br /> Run by * Pagel <br /> Facility Information as of 6/22/2011 <br /> Record Selection Criteria: Facility ID FA0015852 <br /> OWN <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> SSN/Fed Tax ID <br /> Owner ID OW0012775 New Owner ID <br /> Owner Name RP <br /> Owner DBA P <br /> Owner Address P - <br /> H <br /> Home Phone 717- B6-744.6 <br /> Work/Business Phone Not Specified <br /> Mailing Address F - <br /> 1 <br /> Care of C+rE-N- @S-FER <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0015852 <br /> Facility Name S.IC���F-gNdl Y URRENT VF <br /> Location 1950 W FREMONT ST <br /> STOCKTON, CA 952032041 <br /> Phone <br /> Mailing Address P 2 <br /> H 1 <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 13336040 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact NameGtEN-FOST—ETr <br /> Title <br /> Day Phone Z1 7 Qa 7;1 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0027560 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Nameafe����=R SNT VAC) (Circle One) <br /> Account Balance as of 6/22/2011: $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 /> 2959-DTSC- HW SITE PR0523458 EE0000684-MICHAEL INFURNA 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 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. 4,, <br /> APPLICANT'S SIGNATURE: e e ��"-�"�"' Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> RENS: Date / / Account out: Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />