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Date run : 5/24/00 8 :26AM SA AQUIN COUNTY PUBLIC HEALTH SE ES Report #: 0002 <br /> Run by ssASSON Facility Information as of 5/24/00 Page #: 1 <br /> Record Selection Criteria: Facility ID FA0012304 <br /> Record to <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE (date) <br /> OWNERSHIP CHANGE (date) <br /> OWNER FILE INFORMATION <br /> Owner to: OW0009539 Ne O r)er ID <br /> Owner Name; SANTANA, ALFONSO <br /> Owner DBA: <br /> Owner Address; / <br /> Home Phone; 209-467-7-830gsj — 0 g 4 <br /> Work/Bussness Phone; Not Specified +-R V-- <br /> Mailing Address; 7§�-S+f(7NR@E �0 <br /> 6- -� ss�r <br /> Care of: SANT1kNArALJ&Q O T n1 40 JImevl <br /> FACILITY FILE INFORMATIONVIC- <br /> rr <br /> FacilityID: FAD012304 CL. do) <br /> Facility Name: E <br /> Location; 2070 S EL DORADO ST <br /> STOCKTON, C 5206 <br /> Phone; 209-464-93ty g910;L- <br /> Mailing Address:--2@55-6-MC61R4aE I�>- <br /> STOCKTON, CA 95206-Sivt4 okl?0� <br /> Care of; ALFONSO SANTANA M <br /> o iirnt;tlt-cam <br /> Location Code: APN: <br /> BOS District; SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0020046 New Account to:: <br /> Mail Invoices to; Owner Mall Invoices to: Owner/Facility/Account <br /> Account Name: SANTANA, ALFONSO (Circle One) <br /> Account Balance as of 5/24/00: $210.00 <br /> (Circle One) <br /> UST(s) Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status Linked New Owner? Delete <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FI PRO515762 EE0000451 -SASSON Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0515714 EE0000451 -SASSON Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agentof same,acknowledge that all site,and/or <br /> project specific,PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on this <br /> form. 1 also certify thata0 operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and State and/or Federal <br /> Laws. <br /> APPLICANT'S SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: '$0.00= Amount Paid Date <br /> Water System to be TRANSFERED: "$150.00= Amount Paid Date <br /> Payment Type Check Number Receipt Number Received by <br /> REHS: Date / / Account out: Date <br /> 1.0.0.89.00 <br />