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Dale run P/22/2008 3:29:04PN SAN JI*UIN COUNTY ENVIRONMENTAL HEAj DEPARTMENT Report usort <br /> Run by Pagel <br /> Facility Information as of 8/22/2008 <br /> Record Selection Cmeda: Facility ID FA0019100 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) —7 22—C7K <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0007534 New Owner ID <br /> Owner Name STOCKTON NISSAN <br /> Owner DBA STOCKTON NISSAN <br /> Owner Address 3077 E HAMMER LN <br /> STOCKTON, CA 95212 <br /> Home Phone 209-956-1930 <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 691180 <br /> STOCKTON, CA 952691180 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0019100 <br /> Facility Name STOCKTON NISSAN <br /> Location 3077 E HAMMER LN <br /> STOCKTON, CA 95212 <br /> Phone 209-956-1930 <br /> Mailing Address PO BOX 691180 <br /> STOCKTON, CA 952691180 <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> SOS District 003-MOW, VICTOR Fax <br /> APN 12618018 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone 209-956-1930 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0034013 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name STOCKTON NISSAN (Circle One) <br /> Account Balance as of 8/22/2008: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4740-WASTE TIRE SITE-EXEMPT PR0528247 EE0000060-JENNIFER FRASE 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 spec,PHS/EHD hourly charges associated with this <br /> facility or aclivity,will be billed to the parry identified as the OWNER on this torn. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State endlor Federal Laws. <br /> APPLICANT'S 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 Receiv <br /> REHS: Date /2 -/ O Account out: Date <br /> COMMENTS: /. <br /> Ate"" till{�qv�..-- <br /> p�zoosa8��o <br /> \\phs-ehsgl-nt\apps\env4sions\reports\5021.rpt <br />