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Date run 8/15/2003 1:24:21PR SAN JOA^,.NCOUNTY ENVIRONMENTAL HEAL,.,;)EPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/15/2003 <br /> Record Selection Criteria: Facility ID FA0005116 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner I OW0003995 Ulu" New Owner ID <br /> Owner Name SMS BRINER <br /> Owner DBA SMS BRINER'S INC <br /> Owner Address 17750 E HWY 4 2-4 14K Ll— <br /> G <br /> STOCKTON, CA 95206 u d o L tib) <br /> Home Phone 209-941-8515 ✓ �l l` / ��� <br /> Work/Business Phone Not Specified <br /> Mailing Address 17750 E HWY 4 <br /> STOCKTON, CA 95206 <br /> Care of ARNOLD SOUSA <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0005116 <br /> Facility Name SMS BRINER'S INC <br /> Location 17750 E HWY 4 <br /> Phone STOCKTON, CA 95206 0,F) 44�_SS�S <br /> Mailing Address 17750 E HWY4 <br /> STOCKTON, CA 95206 <br /> Ca wef ARfdJtD seUSA <br /> Location Code 99 - UNINCORPORATED AREA APN 183-140-08-06 <br /> BOS District SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0005562 New Account ID: <br /> Mail Invoices to Facility '/ Mail Invoices to: Owner / Facility / Account <br /> Account Name SMS BRINER'S INC (Circle One) <br /> Account Balance as of 8/15/2003: $0.00 ✓ <br /> d'- ✓ ris) <br /> Transfer to Activ reoctus <br /> Program/Element and Description AIL Record ID 1 Employee ID and Name J status New OwneR ate <br /> 29 b12%QUAL&T,�_Fj ECT PRO501477 EE0000684-MICHAEL INFURNA In live Y N A 1 D <br /> a1LLIN and C MPLIANC CK O LEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,an r project specific.PHS/EHD hourly charges associated.1m 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 wgh all applicable Ordnance Codes angler Standards and <br /> Stale and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRAN FERED: '$155.00= Amount Paid Date <br /> Payment Type Check Number_ Received by <br /> REHS: Date I / Account out: Date / 1!7/ 0;� <br /> COMMENTS: <br /> \\Phs-ehsgl-nt\apps\Envisions\Reports\5021.rpt'� � ��1 <br />