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Date run 9/11/2007 3:29:39PR SANJI- WIN COUNTY ENVIRONMENTAL HEP "'H DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9/11/2bD`/ <br /> Record Selection Criteria: Facility ID FA0018129 <br /> Make changes/corrections in RED Ink or pen I. <br /> INFORMATION CHANGE(date) (Ili <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0014872 New Owner ID <br /> Owner Name CARRILLO-GAMSOA, CLEMENTE <br /> Owner DBA <br /> Owner Address 4450 E 4TH ST Eno 0 <br /> STOCKTON, CA 95215 <br /> Home Phone 209-464-1589 lMellrr�. <br /> Work/Business Phone 209-464-4919 <br /> Mailing Address 2300 E WATERLOO RD#3 <br /> STOCKTON, CA 95205 <br /> Care of CARRILLO-GAMSOA, CLEMENTE <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0018129 <br /> Facility Name CHARTER WAY APPLIANCE <br /> Location 920 E CHARTER WAY \ , <br /> STOCKTON, CA 95206 <br /> Phone 209-465-4919 <br /> Mailing Address 2300 E WATERLOO RD#3 <br /> STOCKTON, CA 95205 <br /> Care of CARRILLO-GAMSOA, CLEMENTE <br /> Location Code 01 -STOCKTON \� APN:16718302 <br /> BOS District 001 -GUTIERREZ, STEVE SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0031898 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name CHARTER WAY APPLIANCE (circle One) <br /> Account Balance as of 9/11/2007: $0.00 <br /> (Circle One) <br /> Transferto Active/InacNe <br /> ProgramlElemem and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2217-APPLIANCE RECYCLER PRO526771 EE0008317-RAYMOND VON FLUE Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO526772 EE0008317-RAYMOND VON FLUE Active Y N A (] D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned ovmer,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated wah this <br /> facility or activity vnll be billed to the party Identified as the OWNER on this forth. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANTS SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: "$20.00= Amount Paid Date /_I <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment T Check Number Received <br /> REHS: A 9Date /�,�/�� Account out: Date <br /> COMMENTS: <br /> ZN 4 l- ; LIA 14-. r2 2 z p L, / 1 ��S rti en4U(fs�,4 <br /> 60o-e en U� o <br /> {� cr� i l ej A,54) <br /> \\phs-ehsgl-nt\apps\envisions\reports\5021.rpt <br />