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Date mn 1/29/2004 10:58:58AI SAN JOA'—TIN COUNTY ENVIRONMENTAL HEAL---.DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 1/29/200zr,04 Paget <br /> Record Selection Criteria. Facility to FA0009869 <br /> Make changes/corrections in RED Ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0007869 Case Number: H05686 New Owner ID <br /> Owner Name VICTORINE,VINCENT C µ r/ kGB v WK�977Gr, ar <br /> Owner DBA JM EQUIPMENT CO INC <br /> Owner Address 1245 W CHARTER WAY <br /> STOCKTON, CA 95206 <br /> Home Phone 209-652-7654 <br /> Work/Business Phone Not Specified <br /> Mailing Address 819 S NINTH ST <br /> MODESTO, CA 95351 <br /> Care of VINCENT VICTORINE <br /> FACILITY FILE INFORMATION ?A <br /> Facility ID FA0009869 <br /> Facility Name JM EQUIPMENT CO INC <br /> Location 1245 W CHARTER WAY <br /> STOCKTON, CA 95206 <br /> Phone 209-466-0707 <br /> Mailing Address 1245 W CHARTER WAY <br /> STOCKTON, CA 95206 <br /> Care ofI�(N ryZyITp}ttNE'' <br /> Location Code O STOCKTON APN:163-230-34-5 <br /> BOS District 001 -GUTIERREZ, STEVE SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016869 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name JM EQUIPMENT CO INC (Circle One) <br /> Account Balance as of 1/29/2004: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner/ Delete <br /> 2220-SM HW GEN<5 TONSNR PR0514071 EE0007380-STEVEN SHIH Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0512157 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PR0520938 EE00OOOOO-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPRO509869 EE0000000-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 slo,and/or protect specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be bi to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinate Codes and/or Standards and <br /> State andlor Federal Laws. <br /> APPLICANTS SIGNATURE: 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 Receive�d pb�y <br /> REHS: Date / / Account out: �L Date I / <br /> COMMENTS: <br /> \\Phs-ehsgl-nt\apps\Envisions\Reports\5021.rpt <br />