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para run` 9/20/01 3:49:14PM SA QUIN COUNTY PUBLIC HEALTH SE �$ Rage #. soz1 <br /> Page #: 1 <br /> Run by `'�f Facility Information as of 9/20/01 <br /> Record Selection Criteria: Facility ID FA0009240 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID: OW0007240 Case Number: H02322 New Owner ID <br /> Owner Name: BARBARA—WALKER— A-r <br /> Owner DBA: �" <br /> Owner Address: 3 2 0? Av�&t+r.. Clue G• 2 <br /> CTO a2 t <br /> Home Phone: Ne-$peejW K77 — 4$Coen <br /> Work/Business Phone: 209-957-9361 <br /> Mailing Address: 3201 W BEN HOLT DR#119 <br /> STOCKTON, CA 95219 <br /> Care of: �I I <br /> FACILITY FILE INFORMATION S S/V— S 7 2.— 71— S?CO <br /> Facility ID: FA0009240 <br /> Facility Name: ELITE CLEANERS <br /> Location: 3201 W BENJAMIN HOLT DR 119 <br /> STOCKTON, CA 95219 20 <br /> Phone: 209-957-9361 <br /> Mailing Address: 3201 W BENJAMIN HOLT DR <br /> STOCKTON, CA 95219 <br /> Care of: BARBARA WALKER <br /> Location Code: 01 -STOCKTON APN: 100-170-09 <br /> BOS District: 002 - MARENCO, DARIO SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0016240 New Account ID: <br /> Mail Invoices to: Accoun Mail Invoices to: Owner act ity Account <br /> One) <br /> Account Name: ElLixt AN <br /> Account Balance as of 9/20/ $210.00 <br /> (Circle One) <br /> Transfer to Active/Inache <br /> PmgraMElement and Description Record ID Employee ID and Name Stabis New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0513720 EE0000418-MICHAEL KITH Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0511528 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE F PR0509240 EEo000000-HAZ MAT SJC DES Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project 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. Ialso certify that all operations will be performed in accordance with all applicable Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> /ati/U -q I Iol <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: -$2'.00=o4/O.c9a nt Paid Date !I /� <br /> Water System to be TRANSFERED: '$150.0 mount Paid Date / / <br /> Payment Type ✓ Check Number �oZ.$-` Received by�- .a y� 0� <br /> REHS: Date I l Account out: Lk,'-t, Date <br /> COMMENTS: <br /> PAYMENT <br /> RECEIv1En <br /> \\Phs-ehsgl-nt\apps\Envisions\Reports\5021.rpt <br />