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D,1' 4006 <br /> :;/26/2009 4:25:08PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run y <br /> Facility Information as of 5/26/2009 Pagel <br /> Record Selection Criteria: Facility ID FA0016125 <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 OW0013025 New Owner ID <br /> Owner Name THOMAS, RANDALL F 1 r) <br /> Owner DBA @�,� 9YtB��.ip..S <br /> Owner Address 21710 N MAY RD <br /> ACAMPO, CA 95220 <br /> Home Phone 209-955-2022 <br /> Work/Business Phone Not Specified <br /> Mailing AddressND-C-ANAL-BtVf) STE`"�6 <br /> SIO-CISTON, CA 95207, in C ,� rn A0 `rJr�;—A <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0016125 R F iese <br /> Facility Name <br /> Location 2303 WEST LN <br /> STOCKTON, CA 95205 <br /> Phone <br /> Mailing Address - S <br /> ernrv-rnnl re oG�m <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 002- RUHSTALLER, LARRY Fax <br /> APN 11709027 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name THOMAS, RANDALL <br /> Title <br /> Day Phone 209-955-2027 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID ,AR00281� C ..O. New Accou <br /> I,�`,ItJI ^A�10 <br /> Mail Invoices to -Account �— I Mail Invoices to: Owner Facility / Account <br /> Account Name 6L:6JON GRO1IP SERVICES ,r�1 -__„ ,,, �r (Circle One) <br /> Account Balance as of 5/26/2009: $-46.50 <br /> I" (Circle One) <br /> Y Transfer to Active/Inaclve <br /> Program/Element and Description Record ID Employee ID and Name Status New Omen Delete <br /> 2950-ENVIRON ASSESS PR0523970 -I •5 Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operatdrRor agent of aama�acknoy{eage mar t all she,andior project specific,PHS/EHD hourly charges associated with this <br /> facility or activity Wil 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 andror Federal Laws. �� 1, 1� <br /> APPLICANT'S SIGNATURE: "`"" A-r7'+CSC� Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: "$372.00= Amount Paid 37 Datel'f. l_L <br /> Payment Type LI/ Check Number Received by_'� _ <br /> REHS: `� 1\ Date Accountout: �� Date _/_;Llf/ 0 7 <br /> COMMENTS: <br /> \\eh-env\envis ion\reports\5021.rpt • <br />