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Date run 7/22/2010 1:08:57PR SAN'JIRepon#5021 <br /> 2UIN COUNTY ENVIRONMENTAL HEP' �'-H DEPARTMENT <br /> Run by <br /> Facility Information as of 7I22I2b1t` pager <br /> Record Selection criteria: Facility ID FA0009240 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN I Fed Tax ID <br /> Owner ID OW0007240 Case Number: H02322 New Owner ID <br /> Owner Name PATEL, DIMPLE & HINA <br /> Owner DBA ELITE CLEANERS <br /> Owner Address 3589 W BENJAMIN HOLT DR APT 189 <br /> STOCKTON, CA 95219 <br /> Home Phone 209-955-6878 <br /> Work/Business Phone 209-957-9361 <br /> Mailing Address 3589 W BENJAMIN HOLT DR #189 <br /> STOCKTON, CA 95219 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009240 <br /> Facility Name ELITE CLEANERS <br /> Location 3201 W BENJAMIN HOLT DR STE 119 <br /> STOCKTON, CA 95219 <br /> Phone 209-957-9361 <br /> Mailing Address 3201 W BENJAMIN HOLT DR#119 <br /> STOCKTON, CA 95219 <br /> Care of PATEL, DIMPLE&HINA <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002 - RLIHSTALLER, LARRY Fax <br /> APN 10017009 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name PATEL, DIMPLE & HINA <br /> Title <br /> Day Phone 209-957-9361 <br /> Night Phone 209-955-6878 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016240 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name ELITE CLEANERS (circle One) <br /> Account Balance as of 7/22/2010: $7 32q,r;7 <br /> (Girds oris) <br /> Transfer to Activelinactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> M HW GEN<5 TONS/YR PRO513720 EE0004636-GARRETT BACKUS Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO511528 EEOOOOOOO-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PRO520909 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPRO509240 EE000o000-HAZ MAT SJC CES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PR0531348 Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge Mat all site,and/or project spec,PHS/EHD hourly charges associated with this <br /> facility or activity will W billed to the parry identified as the OWNER on this forth. I also certify that all operations will be performed in accordance with all applicable OrdMace 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: •$372.00= Amount Paid Date / /—70 '0/�p , <br /> Payment Type Check Number Received by / �V <br /> REHS: Date � Date <br /> pN <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt •--� S �, �, �/ >� �,-L ll p L' <br />