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Date run 2/17/2015 11:40:02AI SAN JCti„4IDN COUNTY ENVIRONMENTAL HEA..itl DEPARTMENT <br /> Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/17/2015 <br /> Record Selection Criteria: Facility ID FA0003660 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN/Fed Tax ID : <br /> Owner ID OW0009014 Case Number: H09156 New Owner ID <br /> Owner Name Brian Very— Rebecca Very <br /> Owner DBA ELESCO <br /> Owner Address 170 MCCORMICK AVE IS <br /> COSTA MESA, CA 926263307 <br /> Home Phone Not Specified <br /> Work/Business Phone 949-218-3502 <br /> Mailing Address 24031 Dory Drive <br /> Laguna Niguel, CA 92677 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0003660 10417681 <br /> Facility Name ELESCO <br /> Location 2735 Teepee Dr Ste A <br /> Stockton, CA 95205 <br /> Phone 209-464-2288 x <br /> Mailing Address 170 McCormick Avenue <br /> Costa Mesa, CA 92626 <br /> Care of Richard Morris <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 002 - MILLER, KATHERINE Fax <br /> APN EMail <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name Richard Morris <br /> Title office manager <br /> Day Phone 209-465-3500 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003238 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name ELESCO (arae One) <br /> Account Balance as of 2/17/2015: $365.00 <br /> (Circe One) <br /> Transferto Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name status New Owne0 Delete <br /> 1921 -HMBP-Regular-Primary Location PR0538681 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0232567 EE0000008-LETITIA BRIGGS Inactive Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ander project specific,PHS(EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER an this form. I also certify that all operations will be Performed in accordance with all applicable Ordinance Codes andor Standards and State ands <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> PaymentT��((p�eI Check Number C' Receivyd by <br /> REHS: ��/('S A 0— Date - - /��/�_ Account out: - Date Z l_JZIL�,Z <br /> COMMENTS: <br /> PCfLI� ftcb4 �YA l (lq <br /> i �Pt PLUS- 4usf 4 pas , <br />