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Date run 4/24/2003 12:16:21PI SAN JCS IN COUNTY ENVIRONMENTAL HEA f DEPARTMENT Report#5021 <br /> Run by %-'_ Pagel <br /> Facility Information as of 4/24/20(ns/ <br /> Record Selection Criteria: Facility ID FA0012655 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE (date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0009852 New Owner ID <br /> Owner Name BONADONNAS ASPHALT REPAIR <br /> Owner DBA <br /> Owner Address 3883 S EL DORADO ST <br /> STOCKTON, CA 95206 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 3883 S EL DORADO ST <br /> STOCKTON, CA 95206 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012655 <br /> Facility Name BONADONNAS ASPHALT REPAIR <br /> Location 3883 S EL DORADO ST <br /> STOCKTON, CA 95206 <br /> Phone <br /> Mailing Address 3929 HUBBAR" '-3+ ,- <br /> STOCKTON, CA-952T5- J (k-z yi (A-- D:6 7-I <br /> Care of <br /> Location Code 01 - STOCKTON APN: <br /> BOS District 001 - GUTIERREZ, STEVE SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0020956 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name BONADONNAS ASPHALT REPAIR (Circle One) <br /> Account Balance as of 4/24/2003: $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 /> 2390-ABOVEGROUND TANK(SPCC) PR0516518 EE0000451 -STEVE SASSON Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPR0516519 EE0000451 -STEVE SASSON Inactive 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. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$155.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: _ '7�iG Date <br /> COMMENTS: <br /> \\Phs-ehsql-nt\apps\Envisions\Reports\5021.rpt <br />