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Datemn;112/19/2007 10:01:52/ SANJr `2UIN COUNTY ENVIRONMENTAL HEA' TH DEPARTMENT Report#5021 <br /> Run byPaget <br /> Facility Information as of 12/19/217Record Sena: Facility ID FA0009750 <br /> Make changes/corrections in RED ink or penci / <br /> INFORMATION CHANGE(date) 2 <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> Owner ID OW0007750 Case Number: H05328 New Owner ID : <br /> Owner NameS'PdCi$tf �1 P�1�1e �r1G <br /> Owner DBA Ur Py 1 f 4 ,Aub <br /> Owner Address 'Z l�(' SvN-ir11S2, (21 UO . <br /> SAW IAA Chri)JUA CA C? 7 (4 <br /> Home Phone Not Specified <br /> Work/Business Phone <br /> Mailing Address 4221rl AJ4K-9)R <br /> Care of T ,p <br /> FACILITY FILE INFORMATION F�'— <br /> Facility ID FA0009750 <br /> Facility Name ^oTR-&M'11TtAFrtECY1N(` INr V U L L <br /> Location 4223 E CLARK D—R—! <br /> STOCKTON, CA 95215 <br /> Phone 209466-2031 <br /> Mailing Address 4223 E CLARK DR <br /> STOCKTON, CA 95215 <br /> Care of <br /> Location Code 99-UNINCORPORATED AREA APN:17917113 <br /> BOIS District 002- RUHSTALLER, LARRY SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016750 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name ARTHUR C GUSTAFSON Girds One) <br /> Account Balance as of 12/19/2007: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delta <br /> 2217-APPLIANCE RECYCLER PRO521482 EE0005642-MICHELLE HENRY Inactive N A I D <br /> 2220-SM HW GEN<5 TONSNR PRO514019 EE0008317-RAYMOND VON FLUE Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO512038 EEo000000-HAZ MAT SJC DES Inactive N A I D <br /> 2244-PACT TRANSFER RECORD-DES PRO519846 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPR0509750 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO523520 EE5555555-Garrett Alias-Backus Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party identified as the OWNER on this form. 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 / / <br /> Water System to be TRANSFERED: _*$372.00= Amount Paid Date <br /> Payment Type Check Number Re iv y <br /> REHS: �1- i�5 JiJLA� Date 11 /On Account out: <br /> COMMENT) p `� <br /> {� C>?y 1('_1Jr �J`� � �� n eW ©t^j I -&-u <br /> Bed 1 �I I � I o 7 <br /> \\phs-ehsq)-nt\apps\envisions\Teports\5021.rpt <br />