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Date run 3/27/2009 11:44:22AI SAN JOA 'IN COUNTY ENVIRONMENTAL HEAL``DEPARTMENT Report n5021 <br /> Pagel <br /> Ranby <br /> Facility Information as of 3/27/200a <br /> Record Selection cmena: Facility ID FA0015751 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0012682 New Owner ID <br /> Owner Name JAMES HOLLAND <br /> Owner DBA JIM HOLLAND ALIGNMENT& BRAKE <br /> Owner Address 2335 E WATERLOO RD <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-941-6004 <br /> Mailing Address 2335 E WATERLOO RD <br /> STOCKTON, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION 1 J <br /> FacilitylD FA0015751 Pa PL <br /> Facility Name JIM HOLLAND ALIGNMENT& BRAKE INC <br /> Location 2335 E WATERLOO RD <br /> STOCKTON, CA 95205 <br /> Phone 209-941-6004 x0 <br /> Mailing Address 2335 E WATERLOO RD <br /> STOCKTON, CA 95205 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0027283 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name JAMES HOLLAND (Circle One) <br /> Account Balance as of 3/27/2009: $0.00 <br /> (Circle One) <br /> Transferto Active/Inadve <br /> Program/Element and Description Record ID Employee 10 and Name Status New Owner? Delete <br /> 2244-PACT TRANSFER RECORD-DES PR0523322 Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersignetl owner,operator or agent of same,acknowledge that all site,antllor project specific,PHS/EHO hourly charges associated with this <br /> fadiity 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 Ordinace Codes and/or Standards and <br /> State anovor Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment IT Check Number Received b <br /> RENS: Date 3 /.�.�. / rL' Account out: Date ;� l :5J, / U <br /> COMMENTS: /// _�J`' <br /> -\ D <br /> \\eh-env\envision\reports\5021.rpt <br />