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Run by : NORA Sa�rwjoaquin County PHS/EHD <br /> Report #5021 FACILITY INFORMATION as of 04/07/95 <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> Make changes/corrections in RED pen or pencil: <br /> OWNER FILE INFORMATION oat INFORMATION CHANGE: <br /> Date OWNERSHIP CHANGE: <br /> OWNER ID: 004671 New Owner D. 0 <br /> Owner Name: <br /> Owner DBA: <br /> Owner Address: — <br /> STOCKTON, CA <br /> Home Phone: 2 - [T DS' Ir _ - d3z?.3 <br /> Work/Business Phone: <br /> Mailing Address: 3 4 �-- <br /> Care of: ORATION <br /> -cz��szai <br /> FACILITY FILE INFORMATION <br /> FACILITY ID. 005952 <br /> Facility Name: BRANNON TIRE <br /> Location: 540 N HUNTER ST <br /> STOCKTON 95202 <br /> Phone: <br /> Mailing Address: 517 N HUNTER <br /> care of: WAGNER RATION <br /> TON, CA 95202 <br /> Location Code. 01 APN: <br /> BOS District: SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ACCOUNT ID: 0006956 New Account ID: 000 <br /> Mail Invoices to: Facility Mail Invoices to: Owner / FaCility <br /> Account Name: BRANNON TIRE <br /> Account Balance as of 04/07/95 $ 0 . 00 <br /> Record UST(s) Transfer to Activate / Inactivate <br /> P/E Description ID Employee Status Linked new owner? Delete <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> 2450 ENVIRON ASSESS PR503732 0451 SASSON INACTIVE Y N A I D <br /> PUBLIC WATER SYSTEM <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 /> Programs to be TRANSFERED: x = Amount Paid Date <br /> Payment Type Check # Recvd by <br /> ------------------------------------------------------------__ <br /> REHS or COUNTER SUPV: 7S� Date ACCT out: Date q / -7 /9_.5�_ UNIT/File: / /9_ <br />