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Date run 11/17/2003 1:17:03P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 11/17/2003 Pagel <br /> Record Selection Criteria: Facility ID FA0014099 <br /> Make changes/corrections in RED Ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> Owner ID OW0011161 New Owner ID <br /> Owner Name UNIFIRST CORP <br /> Owner DBA <br /> Owner Address 68 JONSPIN RD <br /> WILMINGTON, MA 018871086 <br /> Home Phone 209-941-8364 <br /> Work/Business Phone Not Specified <br /> Mailing Address 68 JONSPIN RD <br /> WILMINGTON, MA 018871086 <br /> Care of UNIFIRST CORPORATION <br /> FACILITY FILE INFORMATION \0 <br /> Facility ID FA0014099 <br /> Facility Name UNIFIRST CORP l �y� <br /> Location 125 E FLORA RDI <br /> STOCKTON, CA 95202 <br /> Phone 209-941-8364 <br /> Mailing Address PO BOX 877 <br /> STOCKTON, CA 95201 <br /> Care of PETER BERNADICOU <br /> Location Code 01 -STOCKTON APN: <br /> BOS District SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0023836 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name UNIFIRSTCORP (circle One) <br /> Account Balance as of 11/17/2003: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record lD Employee lD and Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PR0518723 EE0000684-MICHAEL INFURNA 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,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party idenfified as the OWNER on Nis 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. <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 by <br /> RENS: Date I / Account out: Date <br /> COMMENTS: <br /> \\Phs-ehsq l-nt\apps\Envisions\Reports\5021.rpA <br />