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Daterim 3/10/2003 4:53:081ak SAN JOAQ 'N COUNTY ENVIRONMENTAL HEALT' `EPARTMENT Report#5021 <br /> Pagel <br /> Run by <br /> Facility Information as of 3/10/2003`' <br /> Record Selection Criteria: Fachly ID FA0010042 <br /> Make changes/corrections In RED Ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0007975 Case Number: H06100 New Owner ID <br /> Owner Name OLIVER 8r WINSTON <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 818-972-1200 <br /> Mailing Address 2166 W BROADWAY#557 <br /> ANAHEIM, CA 928042446 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010042 <br /> Facility Name WINSTON TIRE CO#120 <br /> Location 923 S CHEROKEE LN <br /> L95240 <br /> Phone 209-309-3 69-9-1025 <br /> Mailing AddressvAhWili 5,6 7 <br /> 5 —a qlle. <br /> Care of CHRIS BROSSMAN <br /> Location Code 02-LODI APN:047-390-06 <br /> Bos District 004-SEIGLOCK, JACK SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017042 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name WINSTON TIRE CO#120 (Circle One) <br /> Account Balance as of 3/10/2003: $217.50 <br /> (Circle one) <br /> Transfer to Activellnactve <br /> PrograMElemern and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONSNR PR0514141 EE0008389-DENNIS CATANYAG Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0512330 EE000o00O-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPR0510042 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSIEHO hourly charges associated with this <br /> facility or activity we be beed to M party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinate Codes arWor Standards and <br /> State andlor Fedeml Laws. <br /> APPLICANTS SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$155.00= Amount Paid *jDate�/ <br /> Payment Type Check Number <br /> REHS: Date / / Account out: 1 <br /> COMMENTS: <br /> \\Phs-ehsgl-nt\apps\Envisions\Reports\5021.rpt <br />