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Date run 6/27/2008 9:03:27Ah SAN JOA.j§IN COUNTY ENVIRONMENTAL HEALDEPARTMENT Report#5021 <br /> Run by 5290 Pagel <br /> Facility Information as of 6/27/200 <br /> Record Selection Criteria: Facility ID FA0004083 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0003001 New Owner ID <br /> Owner Name CCJS LIMITED PARTNERSHIP <br /> Owner DBA MAN 4LFACTt IRIN jNC <br /> Owner Address 6653 EMBARCADERO DR STE M <br /> STOCKTON, CA 95219 V <br /> Home Phone 209-943-1981 LA4 Met / <br /> Work/Business Phone 209-943-1981 <br /> Mailing Address 6653 EMBARCADERO DR / <br /> STOCKTON, CA 95219 LAAAqlV�C. <br /> Care of BRANDON SCOTT <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0004083 <br /> Facility Name RE MANUFACTURING INC LA <br /> Loc-4tion JAKE CHARTER WAY <br /> KK STOCKTON, CA 95208 <br /> Phone 209-943-1981 <br /> Mailing Address 6653 EMBARCADERO DR nloy �� ( C/Or <br /> STOCKTON, CA 95219 <br /> Care of BRANDON SCOTT <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District Fax <br /> APN EMail <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION � { <br /> Contact Name REMANUFACTURING/S.MOORE t4uY�LI <br /> Title A65 PK 6 QJ <br /> Day Phone 209-943-1981 RLM �q — <br /> Night Phone 209-943-1981 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION S e t/i rjj- Ch eA M G✓ <br /> Account ID AR0003743 vvvNew Account ID: : /� <br /> Mail Invoices to Account M'"ail Invoices tq: Owner / Facility / Account <br /> Account Name r~c^\/AA Co CtJ\/ID °MENTAL � f-�S 0bl -fes (Girds One) <br /> Account Balance as of 6/27/2008: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inacive <br /> Program/Element and Description Record ID Ellyes ID and Name060: Status New Owner? Delete <br /> 2960-RWQCB SITE PR0009048 EE0000684-MICHAE NA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same, cknowledge 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 on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. p' <br /> APPLICANT'S SIGNATURE: V �` c Date to ��/ OO <br /> Program Records to be TRANS ERED: `$20.00= Amount Paid4�9 — Date / / <br /> Water System to be T NSE —*$372.00= Amount Paid Date <br /> Payment Type Check Number Received by p' <br /> REHS: Date / / Account out: Date /�7 / DO <br /> COMMENTS: <br /> \\phs�hsq I-nt\apps\envisions\reports\5021.rpt <br />