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/1 o <br /> P:�d6Y• LAURIEB Sa0oaquin County PHS/EHD 46 Report #5021 <br /> FACILITY INFORMATION as of 07/09/99 . <br /> Make changes/corrections in RED pen or pencil! <br /> NER FILE INFORMATION INFORMATION CHANGE (date): <br /> OWNERSHIP CHANGE (date): <br /> OWNER 1D: 009114 CASE # : HO9302 New Owner ID: 00 <br /> Owner Name: ELECTRIC LIGHTWAVE <br /> Owner DHA: <br /> Owner Address: <br /> i <br /> Home Phone: <br /> SOC SecH / Tax IDH: <br /> Ownership Type: <br /> Mailing Address: 1610 ISHI GOTO ST <br /> Care of: <br /> STOCKTON, WA 95206 <br /> FACILITY FILE INFORMATION <br /> FACILITY ID: 011114 � 1 <br /> Facility Name: ELECTRIC LIGHTWAVE <br /> Location: 1610 ISHI GOTO ST <br /> STOCKTON 95206- 36 <br /> Phone: 360-816-5531 / atyz 21QJ0kAAA--' <br /> Mailing Address: 4400 NE 77TH AVE LC 4f� <br /> Care of: <br /> VANCOUVER, WA 98662 <br /> Location Code: APN: <br /> BOB District: SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ACCOUNT ID: 0018114 New Account ID: 000 <br /> Mail Invoices to: Account Mail Invoices to: Owner Facility / Account <br /> Account Name: ELECTRIC LIGHTWAVE circle one) <br /> Account Balance as of 07/09/99 : $28 50 (Circle one) <br /> Record """���✓✓/ UST(s) Transfer to Activate / Inactivate <br /> P/E Description ID Employee Status Linked new owner? Delete <br /> ________________________________________________ <br /> 2399 UNIFIED PROGRAM FAC STATE SERV PR511114 0000 SJC DES ACTIVE Y N A. I D <br /> 2224 HAZ MAT BUSINESS PLAN AUTHORIZ PR513402 0000 SJC OBS ACTIVE Y N A I D <br /> ----------------------------------------C�P�- --ods--------------------- <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 /> .ecords to be TRANSFERED: x $20.00 Amount Paid Date_/ / <br /> Water System to be TRANSFERED: x $150.00 Amount Paid Date_ <br /> Payment Type Check q Recvd by <br /> ____________________________________________________'7--____-__--___________- -___ <br /> REHS or COUNTER SUPV: Date—/—/— ACCT out: th Date 0 f q.49 UNIT/File:_/_/_ <br />