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Date run 6121101 3:36:47PM SAN �XQUIN COUNTY PUBLIC HEALTH SER' ES <br /> Report #: 5023 <br /> Run by �--� Facility Information as of 6121101 Page #: 1 <br /> Record Selection Criteria: Facility ID FA0005116 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID: OW0003995 New Owner ID <br /> Owner Name: SMS BRINER <br /> Owner DBA: SMS BRINER'S INC <br /> Owner Address: 17750 E HWY 4 <br /> STOCKTON, CA 95206 <br /> Home Phone: 209-941-8515 <br /> WorktBusiness Phone: Not Specified <br /> Mailing Address: 17750 E HWY 4 <br /> STOCKTON, CA 95206 <br /> Care of: ARNOLD SOUSA <br /> FACILITY FILE INFORMATION <br /> Facility ID: FA0005116 <br /> Facility Name: SMS BRINER'S INC <br /> Location: 17750 E HWY 4 <br /> STOCKTON, CA 95206 <br /> Phone: <br /> Mailing Address: 17750 E HWY 4 <br /> STOCKTON, CA 95206 <br /> Care of: ARNOLD SOUSA <br /> Location Code: 99- UNINCORPORATED AREA APN: 183-140-08-06 <br /> BOS District: SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0005562 New Account ID: <br /> Mail Invoices to: Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name: SMS BRINER'S INC (Circle One) <br /> Account Balance as of 6121101: $0.00 <br /> (Circ/ <br /> Transfer to Act' nactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2965-H2O QUAL SITE PROJECT PR0501477 EE0000684-MICHAEL INFURNA 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 specific,PHS/EHD hourly charges associated with this <br /> facility or activity <br /> 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 1 / <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: *$150.00= Amount Paid Date ! / <br /> Payment Type Check Number Credit Card Number Received by <br /> REHS: Date /2� 1_0 Y Account out: .,_ Date n(LI�'� !Q� <br /> COMMENTS: <br /> IkPHS-EHSQL-NTIAPPS1Envisions\Client Access\ENVISIONIREPO <br />