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Date run 6/30/2004 2:49:07PN SAN,- ' QUIN COUNTY ENVIRONMENTAL HF "H DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 6/30/2004 <br /> Record Selection Criteria: Facility ID FA0015447 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0012402 New Owner ID <br /> Owner Name CORT, DANIEL <br /> Owner DBA CDS INVESTORS PARTNERSHIP <br /> Owner Address 343 E MAIN ST _ �6 <br /> STOCKTON, CA 95202 <br /> Home Phone 5-5231 <br /> Not Sp <br /> Work/Business Phone Not Specified <br /> Mailing Address 343 E MAIN ST <br /> Care of <br /> STOCKTON, CA 95202 �� ✓✓ <br /> FACILITY FILE INFORMATION <br /> 2 <br /> Facility ID FA0015447 <br /> Facility Name STOCKTON ROYAL THEATRE <br /> Location 1825 PACIFIC AVE 6�� <br /> STOCKTON, CA 95204 (0- L <br /> Phone C <br /> Mailing Address 1825 PACIFIC AVE ` 69 <br /> STOCKTON, CA 95204 $ <br /> Care of DANIEL CORT _ _ jj <br /> Location Code 01 - STOCKTON �"' " �rN 13702042 <br /> BOS District 002 - MARENCO, DARIO SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0026653 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name STOCKTON WORSHIP CENTER (Circle One) <br /> Account Balance as of 6/30/2004: $-279.00 _'l <br /> 6/ Y f - (Circle One) <br /> {v�]CCC��� l Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID a d Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PR0522666 EE000 42-MARG ET LAGORIO Ac' e Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,an r project speck,PHS/EHD hourly charges associated with 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 with all applicable Ordinate Codes and/or Standards and <br /> State 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 TRANSFERED: '$155.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> RENS: Date / U /' Account out: Date <br /> COMMENTS: <br /> ey <br /> \\Phs-ehsgl-nt\apps\Envisions\Reports\5021.rpt FILE COPY <br />