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Date run 2/8/2006 4:32:02PM SAN JC `tUIN COUNTY ENVIRONMENTAL HEA- 'H DEPARTMENT Report#5021 <br /> Run by ' %u/ Pagel <br /> Facility Information as of 2/8/20 <br /> Record Selection Criteria: Facility ID FA0004027 <br /> Make nges/corrections in RED ink or pencil. <br /> / INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date <br /> OWNER FILE INFORMATION <br /> Owner ID OW0010570 New <br /> Owner Name HENDRIX, RICHARD <br /> Owner DBA HENDRIX FORKLIFT SERVICE INC <br /> Owner Address 103 N D ST <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-962-4144 <br /> Mailing Address PO BOX 5217 <br /> STOCKTON, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility I <br /> Facility Namee HENDRIX HENDRIX FORK LIFT INC <br /> Location 103 N E ST <br /> STOCKTON, CA 95205 <br /> Phone <br /> Mailing Address PO BOX 5217 <br /> STOCKTON, CA 95205 <br /> Care of <br /> Location Code 01 -STOCKTON APN:15318001 <br /> BOS District 001 -GUTIERREZ, STEVE SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003663 NewAccount ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name HENDRIX, RICHARD (Circle One) <br /> Account Balance as of 2/8/2006: $7�68� +� <br /> (Circle One) <br /> V/tn' ,1 Q, Transfer to <br /> J4Active/Inacive <br /> Record ID Employee ID and Name Status New Owner? Delete <br /> ProgrsMElemenl and Description <br /> 2221 -USED OIL ONLY-<5 TONSIYR PRO513586 EE0008373-JOHN-JA614£0N Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO511308 EE0000000-HAZ MAT SJC DES Inactive Y N A� D <br /> 2244-PACT TRANSFER RECORD-DES PRO521074 EE0000000-HAZ MAT SJC OES Inactive Y N A D <br /> 2301 -UST STATE SURCHARGE FEE PRO507743 EE0000008-LETITIA BRIGGS Inactive Y N A I D <br /> 2361 -UST FACILITY PR0231555 EE0000008-LETITIA BRIGGS Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPR0507567 EE0000008-LETITIA BRIGGS Inactive 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 Ordmace Codes and/or Standards and <br /> State aMlor 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 Received by <br /> REHS: Date lI Account out: Date lily <br /> COMMENTS: <br /> \\phs-ehsgl-nt\apps\envisions\reports\5021.rpt n\_-0 <br />