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Date run 1/812013 3:58:22PM SAN JO*IN COUNTY ENVIRONMENTAL HEAIODEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 1/8/2013 <br /> Record Selection Criteria Facility ID FA0001919 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0001503 New Owner ID <br /> Owner Name LINCOLN VILLAGE ASSN#10 <br /> Owner DBA LINCOLN VILLAGE ASSN#10 <br /> Owner Address PO BOX 77812 <br /> STOCKTON, CA 95267 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-952-9400 <br /> Mailing Address PO BOX 77812 <br /> STOCKTON, CA 95267 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0001919 <br /> Facility Name LINCOLN VILLAGE ASSN#10 <br /> Location 3314 RIVERTON WAY <br /> STOCKTON, CA 95219 <br /> Phone 209-952-9400 <br /> Mailing Address PO BOX 77812 <br /> STOCKTON, CA 95267 <br /> Care of <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District Fax <br /> APN 10044011 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name KRISS, TOM <br /> Title <br /> Day Phone 209-952-9400 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account lD AR0001926 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility i Account <br /> Account Name LINCOLN VILLAGE ASSN #10 (Circle One) <br /> Account Balance as of 11812013: $0.00 <br /> (Circle One) <br /> Transfer to Activellnacive <br /> Prograrn/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> RETAIL MKT 26-300 SID FT(INCIDENTAL FOPRO521762 EE0000149-RAYMOND BORGES Inactive Y N A I D <br /> 192 'HMBP-Regular-Primary Location PRO629907 EE0006044-LOWELL ALLEN Active Y N A 0 D <br /> 3611 -PUBLIC POOLISPA-PRIMARY PR0360338 EE0000149-RAYMOND BORGES Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH PR0534482 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identifir /edd as the OWNER on this <br /> form. I also certify <br /> /that all operfatiioonnnswill <br /> lbb/}e performed in accordance with all <br /> applicable Ordinance Codes andfor Standards and State andlor <br /> Federal Laws_ � k� ' 1 1 1�I -'� E V r 1 T � F 1 L f/ ` ` V S I' 1'0 S� � 3 �.� d V✓r I[� <br /> APPLICANT'S SIGNATURE: f ll l Date <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date 1 1 Iff <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Receiv y? <br /> REHS: ��" �" Date�1 `�1�_ Account out: Date <br /> COMMENTS: RU ) ) 13 <br />