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Runby : LAURIEB San Joaquin County PHS/EHD Report #5021 <br /> FACILITY INFORMATION as of 04/19/96 <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> Make changes/corrections in RED pen or pencil: <br /> OWNER FILE INFORMATION INFORMATION CHANGE (date): <br /> OWNERSHIP CHANGE (date): <br /> OWNER ID: 002968 New Owner ID: 00 <br /> owner Name: UNION ICE <br /> owner DBA: UNION ICE/DONS DISTRIBUTION <br /> Owner Address: 711 KIMBERLY AVE STE 155 <br /> PLACENTIA, CA 92670 <br /> Home Phone: 209-948-5071 <br /> Work/Business Phone: 209-948-1231 <br /> Mailing Address: 711 KIMBERLY AVE STE 155 <br /> care of: BRETT LARSON <br /> PLACENTIA, CA 92670 <br /> FACILITY FILE INFORMATION <br /> FACILITY ID: 004036 <br /> Facility Name: UNION ICE/DONS DISTRIBUTION <br /> Location: 1320 W WEBER <br /> STOCKTON 95203 <br /> Phone: 209-948-5071 IInnrr <br /> Mailing Address: PO BOX 108 Q10D �*e( Ii�' <br /> care of: MIKE MCNULTY ci 1 `-'. 1'{� <br /> STOCKTONA, CA 95201 11 i� {',( <br /> Location Code: 0 1 <br /> aPN: 145-190-13 <br /> BOS District: SIC Code: APR 2 5 1996 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION ENVIRONMEN AL HEALTH <br /> PERMIT/SERVICES <br /> ACCOUNT ID: 0003677 New Account ID: 000 <br /> MaiL Invoices to: Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name: UNION ICE/DONS DISTRIBUTION (circle one) <br /> Account Batance as of 04/19/96 : $0 . 00 (Circle ane) <br /> Record UST(s) Transfer to Activate / Inactivate <br /> P/E Description ID Employee Status Linked new owner? Delete <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> 2960 RWQCB CLEAN UP SITE PRO12831 0249 MEAYS INACTIVE Y N A I D <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -• - - - - - - - <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or <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 /> --------------------------- <br /> JJ�� � _---------------------- <br /> RENS or COUNTER SUPV: Date ACCT out: Date /� / UNIT/File: <br /> �� t <br />