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Date run 5/30/2014 2:10:55PR SAN JOIN COUNTY ENVIRONMENTAL HEAq DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 5/30/2014 <br /> Record Selection Criteria: Facility ID FA0015875 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0012796 New Owner ID <br /> Owner Name BRITT, SHANE <br /> Owner DBA <br /> Owner Address 1020 E CHURCH ST <br /> STOCKTON, CA 95201 <br /> Home Phone 209-948-9900 <br /> Work/Business Phone Not Specified <br /> Mailing Address 1020 E CHURCH ST <br /> STOCKTON, CA 95201 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0015875 10185043 <br /> Facility Name COLOR PRO 8r PAINT <br /> Location 1020 E CHURCH ST <br /> STOCKTON, CA 95201 <br /> Phone 209-462-4500 <br /> Mailing Address 1020 E CHURCH ST <br /> STOCKTON, CA 95201 <br /> Care of BRITT, SHANE <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 15128003 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0027631 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name BRITT, SHANE (Circle One) <br /> Account Balance as of 5/30/2014: $1,904.25 <br /> (Circle One) <br /> Transfer to Acbvellnadve <br /> Program/Element and Description Record ID Employee ID and Name Status New Omen Delete <br /> 1921 -HMBP-Regular-Primary Location PR0523496 Inactivf Y N AD <br /> 2220-SM HW GEN<5 TONS/YR PR0536586 EE0001421 -STACY RIVERA Active Y N A b D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0536587 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specsc,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the parry identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordnance Codes andor Standards and State ands <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFE D: Amount Paid Date—/ <br /> Payment Type Check Number Racei <br /> REHDate ✓� / / '4 <br /> COMMENTS: Account out: Date / 7Z!9 <br /> Z� <br />