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Date run 10/21/2016 3:59:33F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 10/21/2016 Pagel <br /> Record Selection Criteria: Facility ID FA0023708 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSNI Fed Tax ID <br /> Owner ID OW0022037 New Owner ID <br /> Owner Name DOUGLAS, MIKE & LISA <br /> Owner DBA <br /> Owner Address 490 MOORE RD <br /> WOODSIDE, CA 94062 <br /> Home Phone 660-683-5282 <br /> Work/Business Phone Not Specified <br /> Mailing Address 490 MOORE RD <br /> WOODSIDE, CA 94062 <br /> Care of DOUGLAS, MIKE & LISA <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0023708 <br /> Facility Name DOUGLAS, MIKE & LISA <br /> Location 14788 W CORRAL HOLLOW RD <br /> TRACY, CA 95377 <br /> Phone 650-683-5282 <br /> Mailing Address 490 MOORE RD <br /> WOODSIDE, CA 94062 <br /> Care of DOUGLAS, MIKE & LISA <br /> Location Code 03 -TRACY Alt Phone <br /> BOS District Fax <br /> APN 26321002 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name DOUGLAS, MIKE & LISA <br /> Title <br /> Day Phone 650-683-5282 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0043861 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility ! Account <br /> Account Name DOUGLAS, MIKE & LISA (Circle One) <br /> Account Balance as of 1012112016: $0.00 <br /> (Circle One) <br /> Program/Element and DescriptionRecord ID Employed ID and Name Status Transfer to Aclivellnactve <br /> New Owner? Delete <br /> 1920-HMBP-Common Materials PR0541376 EE0002670-MUNIAPPA NAIDU Active Y N A I D <br /> 8ILL ING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHEHD hourly charges associated with this facility <br /> 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 Ordinance Codes andlor Standards and State andror <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date 1 ! <br /> Water System to be TRANSFERED: Amount PaidDate F 1 <br /> Payment Type Check Number Received by <br /> EHD Staff: Date 1 1 Account out: Date 1 1 <br /> COMMENTS: <br /> Invoice#: <br />