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Date run : 9/8/00 4:25:26PM SAN .F 'QUIN COUNTY PUBLIC HEALTH SERVIr`ES Report #: 0002 <br /> Run by TBRIGGS `'40/ Facility Information as of 9/6/00 *A./ Page #: 1 <br /> Record Selection Criteria: FacilityID FA0010744 <br /> Record <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE (date) <br /> OWNERSHIP CHANGE (date) <br /> OWNER FILE INFORMATION <br /> Owner to: OW0008744 Case Number: H08631 New Owner ID <br /> Owner Name: ART KOROCK <br /> Owner DBA: �,n,(��� <br /> Owner Address: <br /> Home Phone: Not Specified 7 <br /> Work/Bussness Phone: 209-464-6601 <br /> Mailing Address: 1549 N BROADWAY AVE <br /> Care of: <br /> FACILITY FILE INFORMATION <br /> Facility ID: FA0010744 <br /> Facility Name: CUSTOM RV <br /> Location: 1549 N BROADWAY AVE <br /> STOCKTON, CA 95205 20 <br /> Phone: 209-462-6923 <br /> Mailing Address: 1549 N BROADWAY AVE <br /> Care of: ART KOROCK <br /> Location Code: 99- UNINCORPORATED AREA APN: 143-150-23 <br /> BOS District: 001 -GUTIERREZ, STEVE SIC Code; <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0017744 New Account ID:: <br /> Mail Invoices to: Account Mail Invoices to: Owner/Facility/Account <br /> Account Name: CUSTOM RV (Cirde One) <br /> Account Balance as of 9/6/00: $0.00 <br /> -- (Circle One) <br /> UST(s) Transfer to Active/InacIve <br /> Program/Element and Description Record ID Employee ID and Name Status Linked ew Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0514400 EE0000008-BRIGGS Inactive YN 0 D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FE PR0510744 EE0000000-SJC O Inactive Y N D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513032 EE0000000-SJC IJES Inactive Y N I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,o rate agent of sem owledge that all site,and/or <br /> project specific,PHS/EHD hourly charges associated with this facility or activity will be bt o the entified as the BILLING PARTY on this <br /> form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and State and/or Federal <br /> Laws. <br /> APPLICANTS SIGNATURE: Date I I <br /> Program Records to be TRANSFERED: '$0.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$150.00= Amount Paid Date <br /> PaymentTy Check Number Receipt Number Received by <br /> REHS: Date / / Acceuntout: _14Date 99 /D I (fD <br /> rN`'°p �✓` ', <br /> 1.0.0.89.00 <br />