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Run by : CARL Saoioaguin Co;nty, PHS/EHD <br /> Report #5021 FACILITY INFORMATION as of 04/14/95 <br /> - - - - - - - - - - - <br /> Make changes/corrections in RED pen or pencil: <br /> OWNER FILE INFORMATION Date of INFORMATION CHANGE: <br /> Date of OWNERSHIP CHANGE: <br /> OWNER ID: 002671 New Owner ID: 00 <br /> owner Name: BREGANTE, DAVID <br /> Owner DBA: BLUE STAR <br /> Owner Address: 4040 E MAIN ST <br /> STOCKTON, CA 95205 <br /> Home Phone: <br /> Work/Business Phone: 209-462-0124 <br /> Mailing Address: 4040 E MAIN ST <br /> care of: BREGANTE, DAVID <br /> STOCKTON, CA 95205 <br /> FACILITY FILE INFORMATION <br /> FACILITY ID: 003564 <br /> Facility Name: BLUE STAR <br /> Location: 4040 E MAIN <br /> STOCKTON 9520505 <br /> Phone: 209-462-0124 <br /> (ling Address. PO BOX 1562 <br /> C KEVIN BREGANTE <br /> STOCKTON, CA 95201 Tst /c-_ � 7 ( Z D ;7 <br /> Location Code: 0 1 AFN: - <br /> BOS District: SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ACCOUNT ID: 0003142 New Account ID: 000 <br /> Mail Invoices to: Facility Mail Invoices to: Owner / Facility <br /> Account Name: BLUE STAR <br /> Account Balance as of 04/14/95 $2 , 040 . 00 <br /> Record UST(s) Transfer to Activate / Inactivate <br /> P/E Description ID Employee Status Linked new owner? Delete <br /> - - <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - _ _ _ <br /> 2381 UST FACILITY (BEFORE 1/84) PR231666 0008 BRIGGS ACTIVE 3 Y N A I D <br /> PUBLIC WATER SYSTEM <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of 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 <br /> BILLING PARTY on this form. I also certify that all operations will be performed in accordance with all applicable SAN JOAQUIN <br /> COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date_/ /9_ <br /> _ _ _ _ _ _ _ _ _ _ _ _ <br /> Programs to be TRANSFERED: x _ = Amount Paid Date —/—/9— <br /> Payment Type Check # Recvd by <br /> RENS or COUNTER SUPV Date—/—/9— ACCT out: Date /�/9 UNIT/File:_/_/9_ <br /> 1 <br />