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Date run 11/2/01 8:26:02AM SAN .i �AQUIN COUNTY PUBLIC HEALTH SERVII ES Report u: 5023 <br /> Run by Page #: 1 <br /> Facility Information as of 11/2/01 <br /> Record Selection Criteria: Facility ID FA0004535 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID: OW0003443 New Owner ID <br /> Owner Name: TRUSTEE IN BANKRUPTCY/M BOWMAN <br /> Owner DBA: CAL-FARM SUPPLY <br /> Owner Address: PO BOX 570 <br /> PENRYN, CA 95663 <br /> Home Phone: 916-497-1141 <br /> Work/Business Phone: Not Specified <br /> Mailing Address: PO BOX 570 <br /> PENRYN, CA 95663 <br /> Care of: MARTHA BOWMAN <br /> FACILITY FILE INFORMATION <br /> Facility ID: FA0004535 <br /> Facility Name: CAL-FARM SUPPLY <br /> Location: 2040 W WASHINGTON <br /> STOCKTON, CA 95206 <br /> Phone: <br /> Mailing Address: PO BOX 570 <br /> PENRYN, CA 95663 <br /> Care of: MARTHA BOWMAN <br /> Location Code: 01 - STOCKTON APN: <br /> BOB District: SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0004279 New Account ID: <br /> Mail Invoices to: Facility Maillnvoicesto: Owner/Facility/Account <br /> Account Name: CAL-FARM SUPPLY (circle One) <br /> Account Balance as of 11/2/01: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2951 -UGT-CAP PR0001279 EE0000963-DIANE HINSON Active Y N A I D <br /> 2960-RWQCB CLEAN UP SITE PR0506560 EE0000684-MICHAEL INFURNA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror 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 and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANTS SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: •$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: •$150.00= 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 />