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Date rtm 2/2/2002 10:47:35AI SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report M21 <br /> Run by <br /> . Facility Information as of 2/22/2(?me Paget <br /> Record Selection Criteria: Facility ID FA0010133 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHA ate) <br /> OWNER FILE INFORMATION ftrn 77�� <br /> Owner ID OW0008133 Case Number: H06788 New Owner ID : <br /> Owner Name ROBERT CORBITT <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-931-9652 <br /> Mailing Address 9647 LELAND WAY <br /> STOCKTON, CA 95212 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010133 <br /> Facility Name CORBITT'S FOREIGN AUTO REPAIR <br /> Location 3934 CORONADO AVE G <br /> STOCKTON, CA 95204 20 n � <br /> Phone 209-464-9704 <br /> Mailing Address 9647 LELAND WAY <br /> STOCKTON, CA 952122415 <br /> Care of ROBERT CORBITT <br /> Location Code 01 -STOCKTON APN:115-300-32 <br /> BOS District 002 - MARENCO, DARIO SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017133 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name CORBITT'S FOREIGN AUTO REPAIR Circle One) <br /> Account Balance as of 2/22/2002: $217.50 <br /> (Circle Ore) <br /> Transfer to Acgve/hocive <br /> PrograrvElement and Description Record ID Employee ID and Name Status New Owren Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0514188 EE0000418-MICHAEL KITH Active Y N A D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0512421 11110000000-HAZ MAT SJC DES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPR0510133 11110000000-HAZ MAT SJC OES Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owrer,operator or agent of same,acknowledge that all site,and/or project specific,PHSIEHO hourly charges associated with this <br /> tacdity or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations wit be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANTS SIGNATURE: Dale <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$150.00= Amount Paid Date / / <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: 5�� Date <br /> COMMENTS: <br /> \\Phsehsgl-nt\apps\Envisions\Reports\5021.rpt <br />