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Date run 3/20/2007 3:33:20PN SAN JUIN COUNTY ENVIRONMENTAL HEJH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/20/20 <br /> Record Selection Criteria: Facility ID FA0004032 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORM TION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0002967 New Owner ID <br /> Owner Name AMERICAN MOULDING AND MILLWORK <br /> Owner DBA <br /> Owner Address 813 E MAIN ST <br /> SANFORD, NC 27332 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-946-5880 <br /> Mailing Address 516 NEELY CT <br /> SANFORD, NC 27332 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0004032 Site Mitigation Facility <br /> Facility Name FRMR AMERICAN MOULDING & MILLWORIPIte Mitigation Facility <br /> Location 2801 WEST LN <br /> STOCKTON, CA 95208 <br /> Phone 209-946-5880 <br /> Mailing Address 2801 WEST LANE <br /> STOCKTON, CA 95208 <br /> Care of MILL CREEK DEVELOPMENT-WEST LN <br /> Location Code 99 - UNINCORPORATED AREA AF N:11709001 <br /> BOS District 002- RUHSTALLER, LARRY SIC Co e: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003672 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name (Circle one) <br /> Account Balance as of 3/20/2007: $0.00 Su- A+6".A h F(Z <br /> (Circle One) <br /> Transfer to gctive/InacNe <br /> Record ID Employee ID and Name St lus New Owner? Delete <br /> Program/Element and Description <br /> 2951 -UGT-CAP PRO504943 EE0000756-CAROL OZ Inactive Y N A I D <br /> 2953-LCL HW CLEANUP SITE PR0505272 EE0000756-CAROL OZ Inactive Y N A I D <br /> -QQG9•RRWQ�CBB SITE PR0009016 EE0009488--�( A ive Y N A I D <br /> B1CLAdG ark C�WME ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of sartlE,"WnNkthet al Ie andlor'roject specific,PHS/EHD hourty 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 accordan m with all applicable Ordinate Codes and/or Standards and <br /> State andlor Federal Laws. <br /> APPLICANT'S 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 / / Account out: Date <br /> COMMENTS: <br /> t <br /> \\phs-ehsq I-nt\apps\envisions\reports\5021.rpt <br />