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Dalem? 6/15/2005 8:44:37AK SAN,IOVIN COUNTY ENVIRONMENTAL HE DEPARTMENT Report 95021 <br /> Run by Pagel <br /> Facility Information as of 6/15/20 <br /> Record Selection Criteria: Facility ID FA0009975 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0007975 Case Number: H06100 New Owner ID <br /> Owner Name OLIVER &WINSTON <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 818-972-1200 <br /> Mailing Address 2166 W BROADWAY#557 <br /> ANAHEIM, CA 928042446 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009975 <br /> Facility Name WINSTON TIRE CO#183 <br /> Location 1648 E HAMMER LN <br /> STOCKTON, CA 95210 <br /> Phone 209-956-4223 <br /> Mailing Address 2166 W BROADWAY#557 <br /> ANAHEIM, CA 928042446 <br /> Care of <br /> Location Code APN:9428014 <br /> BOS District SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016975 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name WINSTON TIRE CO#183 (Circle One) <br /> Account Balance as of 6/15/2005: $841.50 <br /> (Circle One) <br /> Transfer to Acllvellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner! Delete <br /> 2220-SM HW GEN<5 TONS/YR PRO514117 EE0003580-MICHELLE LE Active Y N A 01 D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO512263 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARlPRO509975 EE0000000-HAZ MAT SJC CES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO523979 EE0004636-GARRETT BACKUS 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 spec,PHS/EHD hourly charges associated with this <br /> facility 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 Ordinace Codes andlor 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: '$155.00= A eGnt Paid Date <br /> Payment Type Check Number ta I Receiv <br /> REHS: Date I l Account out: Date fel l S <br /> COMMENTS: <br /> l f;�/ie , a P 0� a wt Lx�v. ✓�"' �e t Paz a,14 w MAl f uric a vr� <br /> O"� I y, 10o s.� (r°, eco .�irC�•ao ,6-ea.Q� .co . 'Zv- � � � <br /> 11phs-ehsq l-nt\apps\envisions\reports\5021.rpt <br />