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�s <br /> Y ' <br /> Run by STAFF SAI?om�Joaquin County PHS/EHD Report #5021 <br /> FACILITY . INFORMATION as of 07/29/98 <br /> ------------------------------------------------------------------------------- <br /> Make changes/corrections in RED pen or pencil: <br /> OWNER FILE INFORMATION INFORMATION CHANGE (date) : <br /> OWNERSHIP CHANGE (date) : <br /> I <br /> OWNER ID: 002669 New Ow r ID: 00 <br /> Owner Name: <br /> 19 <br /> Owner DBA: ����v' env ii�vo � _ _ <br /> n n n L� TR T <br /> Owner Address: �-aw��'t-tz-i "�''�"�"�'0®R��� —11t,01I <br /> Home Phone-----2-0-9--5--4-6---= <br /> � r <br /> Soc Sec# / Tax ID#: <br /> Ownership Type: 03 PARTNERSHIP <br /> Mailing Address: 17877 VON KARMAN 3RD FLOOR <br /> Care of: A13dE4��iR�R�y nT[7T TT� QTTTV /a1L� r <br /> IRVINE, CA 92714 yJI1 / <br /> FACILITY FILE INFORMATION <br /> FACILITY ID: 004093 <br /> Facility Name: AMER SAVINGS/LIGHTHOUSE SCHOOL <br /> Location: 222 N EL DORADO ST <br /> STOCKTON 95202 <br /> Phone: 209-546-2434 <br /> Mailing Address: 17877 VON KARMAN 3RD FLOOR <br /> Care of: � ��{-rg _ <br /> IRVINE, CA 92714 <br /> Location Code: 01 APN: 139-100-19-2 <br /> BOS District: SIC Code: <br /> I <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ACCOUNT ID: 0003753 I New Account ID: 000 <br /> Mail Invoices to: ` Mail Invoices to: Owner / / Account <br /> Account Name: AMER SAVI S/LIGHTHOUSE� SCHOOL (Circle <br /> Account Balance as of 07/29/98 : $93 . 60 (Circle one) <br /> Record UST(s) Transfer to Activate / Inactivate <br /> P/E Description ID Employee Status Linked .new owner? Delete <br /> a <br /> 2960 RWQCB CLEAN UP SITE PR009146. 0684 INFURNA ACTIVE Y N - A I D <br /> _______________________________________________________________________________ <br /> I <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: .I, the undersigned owner, operator or agent 6f.same, acknowledge that all site and/or <br /> I <br /> project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this form. I also certify that all operations will be performed in accordance with all applicable SAN JOAQUIN <br /> COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date � <br /> ------------------------------------------------------------------------------- <br /> PR Records to be TRANSFERED: x $20.00 = Amount Paid Date <br /> Water System to be TRANSFERED: x $150.00 Amount Paid Date <br /> Payment Type Check # Recvd by <br /> ------------------------ ------------------ -- ------------- <br /> /n///��� ^/ <br /> RENS or COUNTER SUPV: Date -I ACCT out: Date/ /.. UNIT/File: <br /> APT 1 <br /> i <br />