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Date run 12/9/2004 8:47:49AN SANJOIN COUNTY ENVIRONMENTAL HEA JDEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 12I9I2 3 4 <br />raanyw FA0011023 <br />OWNER FILE INFORMATION <br />Owner ID OW0007393 Case Number: H03711 <br />Owner Name <br />JOHN PHILLIPS <br />Owner DBA <br />INTERSTATE TRUCK COLLISION DIV <br />Owner Address <br />1133 BRISTOL AVE <br />STOCKTON, CA 95204 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-944-5821 <br />Mailing Address PO BOX 6463 <br />STOCKTON, CA 95206 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0011023 <br />Facility Name <br />INTERSTATE TRUCK CTR - COLLISION DI <br />Location <br />641 S HARRISON ST <br />STOCKTON, CA 95206 <br />Phone <br />209-467-3561 <br />Mailing Address PO BOX 6463 <br />STOCKTON, CA 95206 <br />Care of <br />Location Code <br />BOS District <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0018023 <br />Mail Invoices to Facility <br />Account Name INTERSTATE TRUCK CTR - COLLISION DI <br />Account Balance as of 12/9/2004: $0.00 <br />/Program/Element and Description Record ID <br />22P9 - PRO514497 <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO513311 <br />2244 -PACT TRANSFER RECORD -OES PR0520616 <br />2399 - UNIFIED PROGRAM FAC STATE SERVICE FPRO511023 <br />Make changes/corrections in RED ink or pencil. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />New Owner I <br />APN 147-040-47 <br />SIC Code:9900 <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this <br />facility or activity will be billed to the parry identified as the OWNER on this form. I also certify that all operations will be pedonned In accordance with all applicable Ordinace Codes and/or Standards and <br />State and/or Federal Laws. <br />APPLICANT'S SIGNATURE: <br />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 <br />a,,,� Check Number Received y <br />RENS: I;/i i� Date _�l I Account out: <br />COMMENTS: <br />47&d --a (/lrfLtKw <br />10 TOn s i;I 02(,V <br />\\phs-ehsql-nt\apps\envisions\reports\5021. rpt <br />(Cirole One) <br />Transferto <br />Amive/Inaclve <br />Employee ID and Name <br />Status <br />New Owner? <br />Delete <br />EE0008844 - DINA CRAW <br />Active <br />Y N <br />A <br />I D <br />EE0000000 - HAZ MAT SJC OES <br />Inactive <br />Y N <br />A <br />I D <br />EE0000000 - HAZ MAT SJC DES <br />Active <br />Y N <br />A <br />I D <br />EE0000000 - HAZ MAT SJC OES <br />Inactive <br />Y N <br />A <br />I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this <br />facility or activity will be billed to the parry identified as the OWNER on this form. I also certify that all operations will be pedonned In accordance with all applicable Ordinace Codes and/or Standards and <br />State and/or Federal Laws. <br />APPLICANT'S SIGNATURE: <br />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 <br />a,,,� Check Number Received y <br />RENS: I;/i i� Date _�l I Account out: <br />COMMENTS: <br />47&d --a (/lrfLtKw <br />10 TOn s i;I 02(,V <br />\\phs-ehsql-nt\apps\envisions\reports\5021. rpt <br />