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Sawn uin County PHS/EHD . w Joa Report #5021 <br /> Run by I3s4JRIEB 4 <br /> FACILITY INFORMATION as of 11/18/96 <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> Make changes/corrections in RED pen or pencil: <br /> OWNER FILE INFORMATION INFORMATION CHANGE (date): <br /> OWNERSHIP CHANGE (date): <br /> OWNER ID: 005820 New Owner ID: 00 <br /> owner Name: BIG VALLEY FORD <br /> Owner DBA: <br /> owner Address: 3282 AUTO CENTER DRIVE <br /> STOCKTON, CA 95212 <br /> Home Phone: <br /> Soc Sec# / Tax ID#: <br /> Ownership Type: 61 CORPORATION <br /> Mailing Address: 3282 AUTO CENTER DRIVE <br /> care of: BIG VALLEY FORD <br /> STOCKTON, CA 95212 <br /> FACILITY FILE INFORMATION <br /> FACILITY ID: 007087 <br /> Facility Name: BIG VALLEY FORD <br /> Location: 3282 AUTO CENTER DRIVE <br /> STOCKTON 95212 <br /> Phone: <br /> Mailing Address: 3282 AUTO CENTER DRIVE <br /> care of: BIG VALLEY FORD <br /> STOCKTON, CA 95212 <br /> Location Code: 0 1 APN: <br /> BOS District: SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ACCOUNT ID: 0010254 New Account ID: 000 <br /> Mail Invoices to: Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name: BIG VALLEY FORD (Circle one) <br /> Account Balance as of 11/18/96 : $0 . 00 (Circle one) <br /> Record UST(s) Transfer to Activate / Inactivate <br /> P/E Description ID Employee Status Linked new owner? Delete <br /> 22 22 �l� a <br /> 27 GEN 5<25 TONS PERMIT PR505926 0606 TREVENA 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 /> APPLICANT'S SIGNATURE: Date <br /> _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ <br /> PR Records to be TRANSFERED: x $20.00 = Amount Paid Date_/ / <br /> Water System to be TRANSFERED: x $150.00 = Amount Paid Date_/ / <br /> Payment Type Check # Recvd by <br /> REHS or COUNTER SUPV Date_/_/_ ACCT out Date—/ /_ UNIT/File:_/_/_ <br />