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Date run 10/14/2008 11:35:53/ SAN JON COUNTY ENVIRONMENTAL HEAL�EPARTMENT <br /> Report 95027 <br /> Run by 14006 ' Pagel <br /> Facility Information as of 10114/20 <br /> Record Selection Criteria: Facility ID FA0013413 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(dale) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID : <br /> Owner ID OW 10549 New Owner ID : /� D 0 1 7 <br /> Owner Name CITY F S KN <br /> Owner DBA A- <br /> Owner Address �NN L ORADO ST <br /> STOIC N, CA 952021997 <br /> Home Phone 209-93 8840 <br /> Work/Business Phone Not Sp ified <br /> Mailing Address 305 N DORADO ST <br /> STO T N, CA 952021997 <br /> Care of KIT WA KER <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013413 <br /> Facility Name <br /> Location 504 WEBER AVE flQf}bCte uNLT <br /> STOCKTON, CA 95202 <br /> Phone 1 <br /> Mailing Address 4 SD6N EL DORADO ST <br /> STOCKTON, CA 952021 <br /> Care of CITY OF STKN <br /> DCFLffMrr— <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District Fax <br /> APN 13737003 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name CITY OF STKN T <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0022380 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name (Circle One) <br /> Account Balance as of 10/14/2008: $0.00 <br /> (Circle One) <br /> Transfer o Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner' Delete <br /> 2960-RWQCB SITE PRO517413 E.EOM6942-10ATMARETTA190l Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of/a�e,acknowledge that all site,ancuor 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 On ince Codes and/or Standards and <br /> State and/or 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 n <br /> REHS: Date / / Account out: ate / <br /> �,v/ O <br /> COMMENTS: <br /> \\phs-ehsgl-nt\apps\envisions\reports\5021.rpt '- <br />