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Record Selection Criteria: Facility ID FA0015622 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0012568 New Owner ID <br /> Owner Name HERREERA, CARLOSA <br /> Owner DBA <br /> Owner Address 1443 APRICOT AVE <br /> PATTERSON, CA 95363 <br /> Home Phone 209-892-7363 <br /> WorkBusiness Phone 209-469-0656 <br /> Mailing Address 1443 APRICOT AVE <br /> PATTERSON, CA 95363 <br /> Care of HERRERA, CARLOS A <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0015622 <br /> Facility Name UNITED WOOD WORKS <br /> Location 4843 E FREMONT <br /> STOCKTON, CA 95215 <br /> Phone 209-469-0656 <br /> Mailing Address 4843-E-FR`EIV[0N-T 143 Anti Qt A( f <br /> llI ^(A 953f 3-975 <br /> Care of STOCKTON, CA 95215 <br /> Location Code 99- UNINCORPORATED AREA APN:NO APN IN PV <br /> BOIS District 002 - MARENCO, DARIO SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0026987 NewAccount ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name UNITED WOOD WORKS (Circle One) <br /> Account Balance as of 4/29/2005: $424.00 <br /> (Circle One) <br /> Transfer to <br /> Active/InaWe <br /> Progran/Elemeat and Description Record ID Employee 10 and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0523134 EE0008373-JOHN JACKSON Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of sane,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party identified as the OWNER an this form. I also certifythat all operations will be performed in accordance with all applicable Ordinate Codes and/err Standards and <br /> State anchor Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: ^$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: *$155.00= Amount Paid Date <br /> Payment Type Check Number Received <br /> REHS: Date / / Account out: Date <br /> COMMENTS: - /��/f/A I.s�,,✓ - , <br /> \\phs-ehsgl-nttappstenvisionsVeports15021.rpt <br />