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Date ran 1/21/2005 1:39:47PR SAN JWTJIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by - I Pagel <br /> Facility Information as of 1/21/20beJ <br /> Record Selection Criteria: Facility ID FA0013506 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0010635 New Owner ID <br /> Owner Name PATTERSON, KERRICK <br /> Owner DBA AUTOMOTIVE LABELS INC <br /> Owner Address 5520 BROME CT <br /> ORANGEVALE, CA 95662 <br /> Home Phone Not Specified <br /> Work(Business Phone 916-988-6246 <br /> Mailing Address PO BOX 1608 <br /> STOCKTON, CA 95201 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013506 1 / <br /> Facility Name AUTOMOTIVE LABELS INC <br /> Location 120 S AURORA <br /> STOCKTON, CA 95202 <br /> Phone 209-464-4088 <br /> Mailing Address PO BOX 1608 <br /> STOCKTON, CA 95201 <br /> Care of <br /> Location Code APN:15122005 <br /> BOS District SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0022608 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name AUTOMOTIVE LABELS INC (Circle One) <br /> Account Balance as of 1/21/2005: $0.00 <br /> (Circle One) <br /> Transferto Active/lnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220- N<5 TONS/YR PRO517570 EE0008373-JOHN JACKSON -Acttm Y IN I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO517572 EEOOOOOOO-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0520866 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPR0517571 EE0000000-HAZ MAT SJC IDES 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 ad'rvity will be billed to the party identified as the OWNER on this forth. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State aia#or 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 Ty p Check Number Received by <br /> REHS: Date I I Account out: Date_I <br /> COMME <br /> \\phs-ehsgl-nt\apps\envisions\reports\5021.rpt <br />