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Date run 1/9/2003 9:47:09AM <br />SAN JO <br />COUNTY ENVIRONMENTAL HE EPARTMENT <br />Report #5021 <br />Pagel <br />Run by <br />Active <br />Facility Information as of 1/9/20 <br />EEOOo0000 - HAZ MAT SJC OES <br />F Record Selection Criteria: Facility ID FA0011023 I <br />OWNER FILE INFORMATION I I�DtL!✓L <br />Owner I OW00090 Case Number: H09171 <br />Owner Nam O ILLIPS <br />Owner DBA <br />Owner Address <br />Make changes/corrections in RED ink or pencil. <br />INFORMATION CHANGE (date) _ <br />OWNERSHIP CHANGE (date) _ <br />New Owner ID : 9U, /9,97%% 3 l <br />Home Phone Not Specified <br />Work/Business Phone 209-944-5821 <br />Mailing Address 825 NAVY -6R• 1� 1 <br />STOCKTON, CA 95206 <br />Care of <br />FACILITY FILE INFORMATION D <br />FacilityID FA0011023 LL > <br />Facility Name INTERSTATE TRUCK CTR - COLLISION DI R Kt a �f} 2 � <br />Location 641 S HARRISON ST <br />STOCKTON, CA 95206 <br />Phone 209-467-3561 �a <br />Mailing Address-42a-NIAVY-BR-- -Rim <br />STOCKTON, CA 95206 <br />Careof KEITH SPRING <br />Location Code APN:147-040-47 <br />BOS District SIC Code: <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0018023VI u) 71V7 <br />Mail Invoices to AeG9Uptr_-*0 VO <br />Account Name INTERSTATE TRUCK CTR <br />Account Balance as of 1/9/2003: $0.00 <br />New Account ID: <br />Mail Invoices to: Owner / Facility / Account <br />Circle One) <br />ProgramfElemem and Description Record ID <br />Employee ID and Name <br />Status <br />2220 - SM HW GEN <5 TONS/YR PRO514497 <br />EE0000418 - MICHAEL KITH <br />Active <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATIO PRO513311 <br />EEOOo0000 - HAZ MAT SJC OES <br />Active <br />2399 - UNIFIED PROGRAM FAC STATE SERVICE FPR0511023 <br />EE0000000 - HAZ MAT SJC OES <br />Active <br />(Circle One) <br />Transfer to Active/Inacive <br />New Owner? Delete <br />Y N A I D <br />Y N A I D <br />Y N A 1 D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project speck, PHS/EHD hourly charges associated with this <br />facility or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes andfor Standards and <br />State and/or Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />REHS: _ <br />COMMENTS <br />\\Phsehsgl-nt\apps\Envisions\Reports\5021.rpt <br />$20.00 = <br />$155.00 = _ <br />Date <br />Date <br />Amount Paid Date <br />Amount Paid Date <br />Re i by <br />Account out: to p-3 <br />