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Date run 9/9/2013 10:29:59AM SAN JC AN COUNTY ENVIRONMENTAL HEAT ' DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9/9/2013 <br /> Record Selection Criteria: Facility ID FA0021900 <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 ID OW0018033 New Owner ID <br /> Owner Name ST JOHNS CORP <br /> Owner DBA COLUMBIA RIVER CORP <br /> Owner Address PO BOX 17095 <br /> PORTLAND, OR 97217 <br /> Home Phone 971-888-5389 <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 17095 <br /> PORTLAND, OR 97217 <br /> Care of BEALL, JAMES (PRESIDENT) <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID/CERS ID FA0021900 <br /> Facility Name MOFFAT BLVD/WATTS EQUIPMENT <br /> Location 1813 MOFFAT BLVD <br /> MANTECA, CA 95336 <br /> Phone 971-888-5389 <br /> Mailing Address PO BOX 17095 <br /> PORTLAND, OR 97217 <br /> Care of BEALL, JAMES (PRESIDENT) <br /> Location Code 05- RIPON Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 22805005 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name BEALL, JAMES <br /> Title PRESIDENT <br /> Day Phone 971-888-5389 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0039885 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name MOFFAT BLVD/WATTS EQUIPMENT (Circle One) <br /> Account Balance as of 9/9/2013: $-875.00 <br /> (Circle One) <br /> Transfer to Active/lnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PR0537932 EE0001699-JOHNNY YOAKUM Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specific,PHS/EHD hourly charges associated with this facility <br /> 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 Ordinance Codes andlor Standards and State andfor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: 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 /> REHS: Date / / Account out: Date <br /> COMMENTS: <br />