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Date run : 9/3/2002 10:14:27AM SAN JOAQUIN COUNTY _ Report #: 5023 <br /> Run by :'n Facility Information as of 9/3/2002 Page #: 1 <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: OW0Q09318 - <br /> Owner Name: WESTERN SQUARE INDUSTRIES INC <br /> Owner DBA: Larry B3Ttk0 <br /> Owner Address: 1621 N BROADWAY Maintenance Dept. Supervisor <br /> STOCKTON, CA 95205 <br /> Home Phone: 209-944-0921 WESTERN SQUARE <br /> Work/Business Phone: Not Specified <br /> Mailing Address: 1621 N BROADWAY I N D U S T R I E S <br /> STOCKTON, CA 95205 <br /> Care of: WESTERN SQUARE INDUSTRIES INC (209)944-0921 1621 N. Broadway <br /> (800)367-8383 Stockton,CA 95205 <br /> FACILITY FILE INFORMATION (209)944-0934 Fax www.weatemsquare.com <br /> Facility ID: 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: -E4RAT^rNS <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: Mail Invoices to: Owner/Facility 1 Account <br /> Account Name: WESTERN SQUARE INDUSTRIES INC (Circle One) <br /> Account Balance as of 91312002: $0.00 <br /> (circle one) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 3030-Ul CONTROL PROG SITE PR0515035 E- Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,ackno2gffetha't all site,an or 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 ail operations will be performed in accordance with all applicable Ordinace Codes andlor standards and <br /> State andfor Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 I <br /> Program Records to be TRANSFERED: `$20.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: "$150.00= Amount Paid Date I / <br /> Payment Type Check Number Credit Card Number Received by <br /> REHS: `-Jk Date 1_�lb 2 Account out: U Date Q'IQI 021 <br /> COMMENTS: <br /> 3 � 1 � ups aid 123 �e y uCLa r d{ r Ab Lbcee ' <br /> llphs-ehsgl-ntlappslenvisionslreports15023.rpt <br />