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Date run 9/18/01 3:59:21PM S IOAQUIN COUNTY PUBLIC HEALTH S ICES Report n: 5023 <br /> Run by Facility Information as of 9/18/01 Page #: 1 <br /> Record Selection Criteria: Facility ID FA0011271 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID: OW0009271 Case Number: H09546 New Owner ID <br /> Owner Name:--Add;;fi pQ .� <br /> Owner DBA: Olt7i(r/l <br /> Owner Address: <br /> Home Phone: Not Specified <br /> Work/Business Phone: Not Specified <br /> Mailing Address: 2150 RIVER PLAZA DR#400 <br /> SACRAMENTO, CA 95833 <br /> Care of: <br /> FACILITY FILE INFORMATION <br /> Facilitya : 271 <br /> Facility Name: IR T-3ST- C <br /> Location: 3202 MOURFIELD AVE <br /> STOCKTON, CA 95206 <br /> Phone: <br /> Mailing Address: 255 PARK SHORE DR <br /> FOLSOM, CA 956304716 <br /> Care of: <br /> Location Code: APN: <br /> BOS District: SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0018271 New Account ID: <br /> Mail Invoices to: Account Mail Invoices to: Owner/Facility/Account <br /> Account Name: <br /> AR TOUGH r, ,. LUL - (circle one) <br /> Account Balance as of 9/18/01: $-10.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0513559 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2390-ABOVEGROUND TANK(SPCC) PR0517488 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE F PRO511271 EE0000000-HAZ MAT SJC OES Active 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 speck,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: "$150.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date 67 <br /> COMMENTS: <br /> /At& <br /> \\Phs-ehsql-nt\apps\Envisions\Reports\5021.rpt <br />