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Ranby : STAFF San Joaquin County PHS/EHD • Report #5021 <br /> FACILITY INFORMATION as of 01/27/97 <br /> ------------ ------------------------------------------------------------------- <br /> Make changes/corrections in RED pen or pexic il: <br /> OWNER FILE INFORMATION INFORMATION CHANGE (date) : <br /> OWNERSHIP CHANGE (date) : <br /> OWNER ID: 003443 N w Owner ID: 00 <br /> Owner Name: TRUSTEE IN BANKRUPTCY <br /> Owner DBA: CAL-FARM SUPPLY <br /> Owner Address: PO BOX 2$'6' Q <br /> DAWI5; CA 9.55� Cwt g$(o <br /> Home Phone: - W 7 _ ( J <br /> Soc Sec# / Tax ID#: <br /> Ownership Type: 01 CORPORATION <br /> Mailing Address: PO Box ✓ ¢� <br /> Care of: D TIS' INE ITWORTH ,xyn <br /> 95617 b� <br /> FACILITY FILE INFORMATION <br /> FACILITY ID: 004535 <br /> Facility Name: CAL-FARM SUPPLY <br /> Location: 2040 W WASHINGTON <br /> STOCKTON 95206 <br /> Phone: <br /> Mailing Aaaresa: PO BO 80 <br /> Care of: CAT INE WHITWORTH <br /> D IS, CA 95617 <br /> Location Code: 01 APN: <br /> BOS District: SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ACCOUNT ID: 0004279 �, New Account ID: <br /> � OQ X 0 <br /> Mail Invoices to: 'Paeittt -O A Mail Invoices to: Owner Facility / Account <br /> Account Name: CAL-FARM SUPPLY ircle one) <br /> Account Balance as of 01/27/97 : $0 . 00 (Circle one) <br /> Record UST(s) Transfer to < <br /> Activate / Inactivate <br /> P/E Description ID Employee Status Linked new owner? ---- Delete---------- <br /> ---- ------------p - ------------- <br /> C ,./���� ------ <br /> 2 UG ---l-------------PR--- - 09 INSON ----- ACTIVE <br /> 23VI D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this form. I also certify that all operations will be performed in accordance with all applicable SAN JOAQUIN <br /> COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> ______________________________ <br /> PR Records to be TRANSFERED: x $20.00 = Amount Paid Date_/ / <br /> Water System to be TRANSFERED: x $150.00 = Amount Paid Date / / <br /> Payment Type �7 Check # Recvd by <br /> RENS or COUNTER SUPV� e <br /> Dat / /iI /�.{ -ACCT out:- Date-/-/- UNIT/File: <br />