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Date run 5/27/2005 9:17:51AN SAN J `UIN COUNTY ENVIRONMENTAL HE `-I DEPARTMENT Report#5021 <br /> Run by <br /> Pagel <br /> Facility Information as of 5/27/200 <br /> Record Selection Criteria; Facility ID FA0012021 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0009318 New Owner ID <br /> Owner Name WESTERN SQUARE INDUSTRIES INC <br /> Owner DBA <br /> Owner Address 1621 N BROADWAY <br /> STOCKTON, CA 95205 <br /> Home Phone 209-944-0921 <br /> Work/Business Phone Not Specified <br /> Mailing Address 1621 N BROADWAY <br /> STOCKTON, CA 95205 <br /> Care of WESTERN SQUARE INDUSTRIES INC <br /> FACILITY FILE INFORMATION <br /> Facility 1D FA0012021 <br /> Facility Name WESTERN SQUARE INDUSTRIES INC <br /> Location 1621 N BROADWAY AVE <br /> STOCKTON, CA 95205 <br /> Phone 209-944-0921 <br /> Mailing Address 1621 N BROADWAY AVE <br /> STOCKTON, CA 95205 <br /> Care of <br /> Location Code 99 - UNINCORPORATED AREA APN: <br /> BOS District 001 -GUTIERREZ, STEVE SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0019074 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name WESTERN SQUARE INDUSTRIES INC (Circle One) <br /> Account Balance as of 512712005: $jD2­27 O Q-0 <br /> /�� �//�' (Circle One) <br /> ( 1f 't1�► '" INtCT- Transfer to Act)ve/lnacive <br /> ProgramlElement and Description Record ID Employee IO and Name Status New Owner? Delete <br /> 3030-UIC PROGRAM SITE PR0515035 EE00 42-M�nawledge <br /> GORIO A e Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator o agent of same, ll site,andlor project specific.PHSIEHD 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 Ordinate Codes andlor Standards and <br /> State andlor Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date ! 1 <br /> Water System to be TRANSFERED: *$155.00= Amount Paid Date 1 / <br /> Payment Type Check Number Receivedb+, <br /> RENS: Date l��! Account out: Dale <br /> COMMENTS: <br /> 11phs-ehsgl-ntla ppslenvisionslrepo rts15021.rpt <br /> GROUND WATER ELEVATION sldranced <br /> WESTERN SQUARE INDUSTRIES GeoEnvironmental, Inc. <br /> 1621 NORTH BROADWAY PRd LCr HO.ACE-NC-@@-0620 FILE:wsmNsv3 �cvxx: <br /> STOCKTON, CALIFORNIA mrK: 2a JULY 2000 n",,,nv:xNu 3 <br />