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425/2003 12:26:40PI SAN J QUIN COUNTY ENVIRONMENTAL HE TH DEPARTMENT Report 116021 <br /> fir, Facility Information as of 9/25/3 Pagel <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 L. `/—C/OBE <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 <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 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Fadlity / Account <br /> Account Name AUTOMOTIVE LABELS INC (Circleare) <br /> Account Balance as of 9/25/2003: $0.00 <br /> Transfer (circle One) <br /> ActivelmocNe <br /> Program/Element and Description Record ID Employee ID and Name States New Ow r7 Delete <br /> 2220-SM HW GEN<5 TONSNR PR0517570 EE0008373-JOHN JACKSON Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0517572 EE0000000-HAZ MAT SJC OES Active Y N A 1 D <br /> 2244-PACT TRANSFER RECORD-DES PR0520866 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPR0517571 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all she.andlor projetl 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 Ordinate Codes and/or Standards and <br /> Stale andlor 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 /> RENS: Date / / Account out: Date <br /> COMMENTS: <br /> \\Phs-ehsgl-nt\apps\Envisions\Reports\5021.rpt �"'� <br />