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Date run '� <br /> es: 6118101 11:13:30AM ' SAN - --IIN COUNTY PUBLIC HEALTH SEP' Report #: 0002 <br /> Run by . : dy ^'` ::r Page #: 1 <br /> Facility Information as of 6118101 � <br /> Record Selection Criteria: Facility ID FA0003924 <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: OW0002902 New Owner ID <br /> Owner Name: MRM ENTERPRISES <br /> Owner DBA: MRM ENTERPRISES <br /> Owner Address: PO BOX 276 <br /> CERES, CA 95307- <br /> Home Phone: 209-537-5954 <br /> worklBussness Phone: 269-537-5954 <br /> yt �� ailing Address: PO BOX 276 <br /> CERE CA 95307- <br /> ° Care of: MRM ENTERPRISES <br /> FACILITY FILE INFORMATION <br /> Facility ID: FA0003924 <br /> Facility Name: MRM ENTERPRISES <br /> Location: 4733 HWY 99 <br /> STOCKTON, CA 95205 <br /> Phone: 209-537-5954 <br /> Mailing Address: IT33 NVVY99 PD, NIX p?710 <br /> A -� <br /> Care of: MRM ENTERPRISES <br /> Location Code: 01 - STOCKTON APN; <br /> BOS District: SIC Code; <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0003516 New Account ID:: <br /> Mail Invoices to: Owner Mail Invoices to: Owner/Facility/Account <br /> Account Name: MRM ENTERPRISES (Circle One) <br /> Account Balance as of 6118101: $0.00 <br /> (Circle One) <br /> UST(s) Transfer to Activellnactve <br /> Prograrn/Element and Description Record ID Employee ID and Name Status Linked New Owner? Delete <br /> 2301 -UST STATE SURCHARGE PR0515553 EE0000008-BRIGGS - Inactive Y N A I D <br /> 2351 -NEW MULTI UST FACILITY PR0232510 EE0000008-BRIGGS Active 3 Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE F PR0507529 EE0000008-BRIGGS Acdve Y N A 1 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific, <br /> PHSIEHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on this form. I also certify that all <br /> operations will be performed in accordance with all applicable Ordinate Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date f f <br /> Program Records to be TRANSFERED: *$0.00= Amount Paid Date I 1 <br /> Water System to be TRANSFERED: '$150.00= Amount Paid Date 1 I <br /> Payment Type Check Number Receipt Number Received by <br /> REHS: Date /J_ Account out: �� Date '7 ! O I <br /> q <br /> 1.0.0.89.00 _. <br />