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Date run 10/18/2004 2:01:06P SAN J UIN COUNTY ENVIRONMENTAL HE 'I DEPARTMENT Report#5021 <br /> Pagel <br /> Run by <br /> Facility Information as of <br /> :r0/18/ <br /> Record Selection Criteria: Facility ID FA0009240 <br /> Make changes/corrections in RQr( if` T <br /> INFORMATION CHAN E(date); ! + <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0007240 Case Number: H02322 New Owner ID <br /> l� <br /> Owner Name lT1E�Ul�rvr 1J. i-A c' ., r^ <br /> Owner DBA ELITE CLEANERS C, <br /> Owner Address '�i S Y w • 4'• -- �' g`r <br /> STOCKTON, CA 95219 <br /> Home Phone Not Specified [2o`I, 9S5' 7g <br /> Work/Business Phone 209-957-9361 <br /> Mailing Address 3201 W BENJAMIN HOLT DR#119 _ <br /> STOCKTON, CA 95219 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility 1D FA0009240 <br /> Facility Name ELITE CLEANERS <br /> Location 3201 W BENJAMIN HOLT DR 119 <br /> STOCKTON, CA 95219 (,-- <br /> Phone (7-04) 95-7-93L1 <br /> Mailing Address 3201 W BENJAMIN HOLT DR#119 <br /> STOCKTON, CA 95219 <br /> Care of <br /> Location Code 01 -STOCKTON f tv CP Lr <br /> BOS District 002- MARENCO, DARIO <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016240 -- <br /> Mail Invoices to Facility Mail Invoices to: OwnerFacility Account <br /> Account Name ELITE CLEANERS (Circle One) <br /> Account Balance as of 10/18/2004: $0.00 <br /> (Circle One) <br /> Transfer to Actwe/InecNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner' Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0513720 EE0003580-MICHELLE LE Inactive Y N I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0511528 EEOOOOOOO-HAZ MAT SJC DES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PRO520909 EEOOOOOOO-HAZ MAT SJC DES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPRO509240 EEOOOOOOO-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 wigs Nis <br /> facility or activity will be billed to the party identified as the OWNER on this form. I also certify Nat all operations will be performed in accordance with all applicable Ordinate Codes and/or Standards and <br /> �I1/State andlor Federal Laws. <br /> / �1PPLICANTs SIGNATURE: /�'t-G LIiLC,'f-G4 d� �2�E---� 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: � (D Date l 6 Account out: Date <br /> COMMENTS: <br /> \\phs-ehsgl-nt\apps\envisions\reports\5021.rpt <br />