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Date run 4/12/2005 11:17:55AI SAN J0#1N IN COUNTY ENVIRONMENTAL HEAI <br /> Run by .,f. ' tIVEPARTMENT Report#5021 <br /> Facility Information as of 4/12/20 Repel <br /> Record Selection Criteria: Facility ID FA0009712 <br /> Make changes/corrections in RED ink or pencil. <br /> 9230-0-19— INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0007712 Case Number: H05200 New Owner ID <br /> Owner Name DAVIDSON, ALVIN <br /> Owner DBA ACME TRUCK PARTS EQUIPMENT INC <br /> Owner Address 3744 MONITOR CIR SOUTH <br /> STOCKTON, CA 95219 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-466-7021 <br /> Mailing Address PO BOX 449 <br /> STOCKTON, CA 95201 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009712 <br /> Facility Name ACME TRUCK PARTS & EQUIP INC <br /> Location 1016 S WILSON WAY <br /> STOCKTON, CA 95205 <br /> Phone 209-466-7021 <br /> Mailing Address PO BOX 449 <br /> STOCKTON, CA 95205 <br /> Care of <br /> Location Code 01 -STOCKTON APN:155-110-01 <br /> BOS District 001 - GUTIERREZ, STEVE SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016712 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name ACME TRUCK PARTS & EQUIP INC (Circle One) <br /> Account Balance as of 4/12/2005: $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 /> 2220-SM HW GEN<5 TONS/YR PR0514000 EE0003580-MICHELLE LE Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO512000 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0519816 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0231295 EE0000008-LETITIA BRIGGS Inactive Y N A I D <br /> 2390-ABOVEGROUND TANK(SPCC) PRO516328 EE0003580-MICHELLE LE Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR,PR0509712 EE0000000-HAZ MAT SJC OES 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 specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: "$155.00= Amount Paid Date <br /> Payment Type Check Number Received by c/ <br /> REHS: Date / / Account out: i Date 4 /ni �J <br /> COMMENTS: <br /> ENVIRONMENTAL HEALTH <br /> NO LONGER INSPECTS <br /> WASTE TIRES— <br /> PROGRAM HAS BEEN <br /> INACTIVATED! <br /> \\phs-eh sgl-nt\apps\envision s\reports\5021.rpt <br />