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Date run : 5/19/00 8:31:25AM SAI )AQUIN COUNTY PUBLIC HEALTH SEt -,ovES Report #: 0002 <br /> Run by LRROWN `..iPage #: 1 <br /> Facility Information as of 5/19/00 <br /> Record Selection Criteria: FacilityID FA0010972 <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: OW0008972 Case Number: H09070 New owLn�grntto <br /> Owner Name: I IOr L1 <br /> Owner DBA: <br /> Owner Address: 3355 N AD ART RD <br /> STOCKTON, CA 95215-2237 <br /> Home Phone; Not Specified <br /> Work/Bussness Phone: 602-305-6099 <br /> Mailing Address: 3355 N AD ART RD <br /> STOCKTON, CA 95215-2237 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID: FA0010972 <br /> Facility Name: <br /> Location: 3355 N AD ART RD <br /> STOCKTON, CA 952152237 <br /> Phone <br /> Mailing Address: 3355 N AD ART RD <br /> STOCKTON, CA 95215-2237 <br /> Care of: DAVID KELLER <br /> Location Code: 99- UNINCORPORATED AREA APN; 087-100-40 <br /> Bos District: 002 - MARENCO, DARIO SIC Code; <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> account ID: AR0017972 New Account ID:: <br /> Mail Invoices to: Account Mail Invoices to: Owner/Facility/Account <br /> Account Name: AUTOMATIC RAIN COMPANY � (Circle One) <br /> Account Balance as of 5/19/00: $110.00 l n w t, / n SM Oo btoua-fru <br /> `9 u D��S'�✓ (Circle One) <br /> UST(s) Transfer to Active/Inacty <br /> Program/Element and Description Record ID Employee ID and Name Status Linked New Owner? Delete <br /> 2220-SM HW GEN c5 TONS/YR PRO514475 EE0000008-BRIGGS Active Y N I <br /> 2381 -UST FACILITY(BEFORE 1/84) PRO502784 EED000451 -SASSON Inactive 2 Y N 1 <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE F PRO510972 EE0000000-SJC OES Active Y N 1 <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PRO513260 EE0000000-SJC OES Active Y N I <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of saw,acknowledge that all site,andlorprol'ed <br /> specifu;PHSBHD hourly charges associated with this facility or activity will be billed to thepan.rdeMr}}r''ed as the BILLING PARTY on thisform. <br /> also certify,that all operations wiB be performed in accordance with all applicable Ordinace Codes andlor Standards and State and/or Federal 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 rr� <br /> REHS: Date / / Account out: Date 05-M <br /> 1.0.0.89.00 <br />