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Date run 7/27/2004 8:52:46AN SAN JO QUIN COUNTY ENVIRONMENTAL HEY DEPARTMENT Report 7/5021 <br /> Run by Facility Information as of 7/27/20CT4` Paget <br /> Record Selection Criteria: Facility ID FA0003833 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0002838 New Owner ID <br /> Owner Name SUPER STORE INDUSTRIES <br /> Owner DBA SUPER STORE INDUSTRIES <br /> Owner Address PO BOX 549 <br /> LATHROP, CA 95330 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-858-2010 <br /> Mailing Address PO BOX 549 <br /> LATHROP, CA 95330 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0003833 <br /> Facility Name SUPER STORE INDUSTRIES' <br /> Location 16888 S MCKINLEY AVE <br /> LATHROP, CA 95330 <br /> Phone 209-858-2010 <br /> Mailing Address 16888 S MCKINLEY <br /> LATHROP, CA 95330 <br /> Care of <br /> Location Code 07- LATHROP APN 195-280-28 <br /> BOS District 003 - MOW, VICTOR SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003421 NewAccount ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name SUPER STORE INDUSTRIES (Circle One) <br /> Account Balance as of 7/27/2004: $0.00 <br /> (Circle One) <br /> Transfer to Active/Incite <br /> Program/Element and Description Record ID Employee ID and Name Status New OwneR Delete <br /> 2214-CaIARP FAC STATE SURCHARGE FEE PRO519004 EE0007289-ALISON YOUNGBLOODActive Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0514244 EE0008317-RAYMOND VON FLUE Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0512527 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> 2226-CaIARP PROGRAM PR0514750 EE0000000-HAZ MAT SJC OES Active Y N A 1 D <br /> 2244-PACT TRANSFER RECORD-OES PR0520183 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2361 -NEW MULTI UST FACILITY PR0232523 EE0008317-RAYMOND VON FLUE Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPR0507490 EE0007289-ALISON YOUNGBLOOD 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 speck,PHS/EHD hcurlycharges associated with this <br /> facility or activity will be billed to the party idenlRed 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. <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 /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\Phs-ehsql-nt\apps\Envisions\Reports\5021.rpt <br />