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Date run s 10/12/2005 2:53:40P SAN JOt&QJTIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Repo%t5021 <br /> R6u by Paget It <br /> Facility Information as of 10/12/2 <br /> Record Selection criteria: Facility ID FAOOD4040 <br /> `` Make changes/corrections in RED ink or pencil. <br /> See- G,tS INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION e.5 Zr<c <br /> Owner ID OW0002970 S f X C c O�t` A Ts��nrto� N�v Owner ID <br /> Owner Name C Q o A c.. <br /> Owner DBA nn, ,t �y—�o� I^Ir-rF!`u Int nr"Ive r <br /> Owner Address 7401 W 129TH ST <br /> OVERLAND PARK, KS 66213 <br /> Home Phone Not Specified <br /> Work/Business Phone 704-752-4430 <br /> Mailing Address 200 N WAGNER AVE <br /> STOCKTON, CA 95215 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0004040 S Q X Co a wt r�cS �vw�o tiers Zvt c . <br /> Facility Name 1 <br /> Location 200 N WAGNER AVE <br /> STOCKTON, CA 95215 <br /> Phone 209-992-1792 <br /> Mailing Address 200 N WAGNER AVE <br /> STOCKTON, CA 95215 <br /> Care of DAVID LIEB <br /> Location Code 01 -STOCKTON APN. <br /> BOB District SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003683 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility ! Account <br /> Account Name CHNOLOGIES CO (Circle One) <br /> Account Balance as of 10/12/2005: $0.00 <br /> (Gives One) <br /> Transfer to Active/Inactve <br /> New Omen Delete <br /> ProgramlElemenlend Description Record to Employee ID and Name Status <br /> 2960-RWQCB SITE PR0009002 EE0000997-HARLIN KNOLL Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor 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 Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: $20.00= Amount Paid Date <br /> Water System to be TRANSFERED: —*$372.00=— Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date_/_/_ Account out: Date <br /> COMMENTS: <br /> \\phs-ehsql-nt\apps\envisions\reports\5021.rpt <br />