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Date run 4/6/2005 2:54:46PM SAN JOAEN"N COUNTY ENVIRONMENTAL HEALTF4 DEPARTMENT Report#5021 <br /> Run by 4006 Pagel <br /> Facility Information as of 4/6/2005 <br /> Record selection Criteria: Facility ID FA0010376 <br /> Make changeslcorrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0008376 Case Number: H07919 New Owner ID <br /> Owner Name RANSOM, TOM S <br /> Owner DBA RANSOM PAINTING CO INC <br /> Owner Address 534 S ANTEROS AVE <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-957-7686 <br /> Mailing Address 534 S ANTEROS AVE <br /> STOCKTON, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010376 <br /> Facility Name RANSOM PAINTING CO INC <br /> Location 534 S ANTEROS AVE <br /> STOCKTON, 2A 95205 <br /> Phone 209-463-1174 <br /> Mailing Address 534 S ANTEROS AVE <br /> STOCKTON, CA 95205 <br /> Care of <br /> Location Code 99 - UNINCORPORATED AREA APN:1572415-1572416 <br /> BOS District 002 - MARENCO, DARIO SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017376 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name RANSOM GCOINC (Circle One) <br /> Account Balance as of 4/6/2005 04.50 <br /> C (Circle One) <br /> -- Transfer to Active/Inadve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner' Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0514302 EE000837 -JOHN JACKS Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPR0512664 EEo000000-HAZWT-SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-IDES PRO520283 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPR0510376 EE0000000-HAZ MAT SJC OES 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 W this form. I also call that all operddons will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State andror Federal Laws. <br /> APPLICANTS 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: Date—/—/ <br /> COMMENTS: <br /> �iJ�GT✓rt;T� !hr-D A-AJ�L,I T D �� ��S <br /> Vhs-ehsgl-nttappstenvisionstreportst5021.rpt )/10 . -r <br />