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Ah <br /> Date run : 7/3/00 9:27:36AM &N AQUIN COUNTY PUBLIC HEAL ES Z Report #: 0002 <br /> Run by VDAVIS Facility Information as of 7/3/00 Page 4: 1 <br /> Record Selection Criteria: Facility ID FA0004574 <br /> Record ID <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE (date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE (date) <br /> Owner ID: OW0003476 New Owner ID <br /> Owner Name: VALLEY CRETE INC <br /> Owner DBA: VALLEY CRETE, INC <br /> Owner Address: 819 SSTANISLAUS <br /> STOCKTON. CA 95206- <br /> Home Phone: 209-466-3156 <br /> Work/Bussness Phone: 209-466-3156 <br /> Mailing Address: 819 SSTANISLAUS <br /> STOCKTON, CA 95206- <br /> Care of: VALLEY CRETE INC <br /> FACILITY FILE INFORMATION <br /> Facility ID: FA0004574 <br /> Facility Name: QUICK CRETE <br /> Location: 819 S STANISLAUS ST <br /> STOCKTON, CA 95206 <br /> Phone: 209-466-3156 <br /> Mailing Address: PA-B69E 74T S-rl+N 15 L j LLS <br /> STOCKTON, CA 95206- <br /> Care of: VALLEY CRETE INC <br /> Location Code: 01 -STOCKTON APN: <br /> BOS District: 001 -GUTIERREZ, STEVE SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> AccountlD: AR0004359 New Account to: <br /> Mail Invoices to: Facility Mail Invoices to: Owner/ Facility/Account <br /> Account Name; QUICK CRETE (Circle One) <br /> Account Balance as of 7/3/00: $10.00 <br /> (Circle One) <br /> UST(s) Transfer to Active/Inacty <br /> Program/Element and Description Record ID Employee ID and Name Status Linked New Owner? Delete <br /> 2381 -UST FACILITY(BEFORE 1/84) PR0231009 EE0000008-BRIGGS Inactive Y N 1 <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE F PRO510486 EE0000000-SJC OES Active Y N <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0512774 EE0000000-SJC OES Active Y N I <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT.• I,the undersigned owner,operator or agent of same,acknowledga that all site,and/or project <br /> spectftg PHS/E11D hourly charges associated with this facility or activity will be billed to the pan idents red as the BILLINGPARTYon thisform I <br /> also certify that all operations will be performed in accordance with all applicable Orrlinace Codes an or,Standards and State and/or Federal 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 /> rna I L>D A>k) 7�)✓o t c�— `7 1>8,ta-tb <br /> 1.0.0.89.00 <br />