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Date run : 9!7/00 10:53:12AM SAN Jr -'1UIN COUNTY PUBLIC HEALTH SERVI' 'S Report#: 0002 <br /> N.0111, Page #: 1 <br /> Run by TBRIGGS <br /> �" Facility Information as of 9/7/00 <br /> Record Selection Criteria: FacilityID FA0010744 <br /> Record ID <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE (date) <br /> OWNERSHIP CHANGE (date) <br /> OWNER FILE INFORMATION <br /> owner ID; OW0008744 Case Number: H08631 New Owner ID <br /> Owner Name: ART KOROCK //Lt ,STDG i 19'22 t�Pf. D7 J� S O <br /> Owner DBA: 61Chi /rt0,[Lp FI LIQ/ P i <br /> Owner Address, <br /> Home Phone; Not Specified <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 (Circle One) <br /> Account Balance as of 9/7/00: $0.00 <br /> (Circle One) <br /> T(s) Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status Li ed New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0514400 EE0000008-BRIGGS Inactive Y N CD D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FE PR0510744 EE0000000-SJC OES Inactive Y N I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513032 EEOOOOOOO-SJC OES Inactive Y N I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or a nt of s e,acknowledge that all site,and/or <br /> project specific,PHS/EFID hourly charges associated with this facility or activity will be billed to the pa y Identified as the BILLING PARTY on this <br /> form. 1 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 /> APPLICANT'S SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: `$0.00= Amount Paid Date / I <br /> Water System to be TRANSFERED: '$150.00= Amount Paid Date <br /> Payment Type Check Number Receipt Number Received by <br /> RENS: Date_ 112 Account out: Date <br /> 4-c-T t/e <br /> 1.0.0.89.00 <br />