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„ ,,y SANDY Sai�oaquin County PHS/EHD 'Vd Report #5021 <br /> FACILITY INFORMATION as of 07/09/99 <br /> - - -------- ------- -------------------------------- <br /> Make changes/corrections in RED pen or pencil: <br /> OWNER FILE INFORMATION INFORMATION CHANGE (date) : <br /> OWNERSHIP CHANGE (date): <br /> OWNER m: 008-88 CASE # : H08920 New <br /> el 00 <br /> Owner Name: Wf�L1I <br /> Owner DBA: <br /> Owner Address: <br /> Home Phone: Jk <br /> Soc Sec# / Tax ID#: <br /> Ownership Type: 01 CORPORATION SAN JOA01' T” <br /> ,'GECC�N�, i <br /> OFFICE OF EMERGENCY SERVICES <br /> Mailing Address: 4211 CORONADO AVE #A <br /> Care of: <br /> STOCKTON, CA 95204 <br /> FACILITY FILE INFORMATION <br /> FACILITY ID: 010883 <br /> Facility Name. METROCALL INC — <br /> Location: 4211 CORONADO AVE A <br /> TOCKTON 95204- 20 <br /> Phone: U 1 foD- 1VJ 0(I <br /> 1 <br /> Mailing Address: 4211 CORONADO AVE STE A <br /> Care of: METROCALL INC N i(A <br /> STOCKTON, CA 95204 <br /> Location code: APN: 115-300-34 <br /> BOS District: SIC Code: 4899 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ACCOUNT ID: 0017883 New Account ID: 000 <br /> Mail Invoices to: Account Mail Invoices to: Owner—/ Facility / Account <br /> Account Name: METROCALL INC (circle one) <br /> Account Balance as of 07/09/99 : $28 . 50 (circle one) <br /> Record UST(s) Transfer to Activate / Inactivate <br /> P/E Description ID Employee Status Linked new owner? Delete <br /> ________________ ________________________________________ _--__-_--_--_ <br /> 2399 UNIFIED PROGRAM FAC STATE SERV PR510883 0000 SJC DES ACTIVE Y N A I D <br /> 2224 HAZ MAT BUSINESS PLAN AUTHORIZ PR513171 0000 SJC DES ACTIVE Y N A I D <br /> ----------------------------------------------- - - ---- - - - - --- - --- - - -------- <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 <br /> BILLING PARTY on this form. I also certify that all operations will be performed in accordance with all applicable SAN JOAQUIN <br /> COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. <br /> Date <br /> APPLICANT'S SIGNATURE: <br /> ____ --------------------------- <br /> ____ ________ ____ __-_-_--c_--_--__- --- <br /> PR Records to be TRANSFERED: x $20.00 Amount Paid Date <br /> Water System CO be TRAN$FERED: x $150.00 a Amount Paid Date_// <br /> Payment Type Check # Recvd by <br /> ----------- ------------ <br /> ------------- <br /> HEMS or COUNTER SUPV: Date-/-/- ACCT out; Date UNIT/File:_/_/_ <br />