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Date run : 3/23/01 9:05:04AM SAN ,'^AQUIN COUNTY PUBLIC HEALTH SERVtf'ES Report #: 0002 <br /> Run by LBROWN Facility-tflformation as of 3/23/01Page #: 1 <br /> Record Selection Criteria: Facility ID FA0012768 <br /> Record ID <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE (date) <br /> OWNERSHIP CHANGE (date) <br /> OWNER FILE INFORMATION <br /> Owner ID: OW0009947 New Owner ID <br /> Owner Name: WIGHT, LAWRENCE <br /> Owner DBA: WIGHT ENTERPRISES <br /> Owner Address: 2390 PHEASANT RUN CIR <br /> STOCKTON, CA 95207- <br /> Home Phone: 209-466-6633 <br /> Work/Bussness Phone: Not Specified <br /> Mailing Address: 130 S WILSON WAY <br /> STOCKTON, CA 95207- <br /> Care of: LAWRENCE WIGHT <br /> FACILITY FILE INFORMATION <br /> Facility ID: FA0012768 <br /> Facility Name: WOODBRIDGE ARLO-STORE#5650 <br /> Location: 18970 LOWER SACRAMENTO RD <br /> WOODBRIDGE, CA 95258 <br /> Phone: 209-466-6633 <br /> Mailing Address: 18970 LOWER SACRAMENTO RD <br /> WOODBRIDGE, CA 95258- <br /> Care of: <br /> Location Code: 99 - UNINCORPORATED AREA APN; <br /> BOS District• SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0021357 New Account ID:: <br /> Mail Invoices to: Account Mail Invoices to: Owner/ Facility/Account <br /> Account Name: ARCO (Circle One) <br /> Account Balance as of 3/23/01: $174.00 <br /> (Circle One) <br /> LIST(s) Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status Linked New Owner? Delete <br /> 2950-ENVIRON ASSESS PRO516743 EE0000997-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,and/or <br /> project specific,PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on this <br /> form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and State and/or Federal <br /> Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: *$0.00= Amount Paid Date <br /> Water System to be TRANSFERED: "$150.00= Amount Paid Date <br /> Payment Type Check Number Receipt Number Received by <br /> REHS: Date / / Account out: Date <br /> 1.0.0.89.00 <br />