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Date run 3/22/2017 12:47:49PP SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 3/22/2017 <br />Record Selection Criteria: Facility ID FA0002422 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0005071 <br />Owner Name <br />LINCOLN VILLAGE HOA#3 <br />Owner DBA <br />OwnerAddress <br />5250 CLAREMONTAVE 141 <br />STOCKTON, CA 95207 <br />Home Phone <br />209-472-3485 <br />Work/Business Phone <br />916-746-0011 <br />Mailing Address <br />5250 CLAREMONT AVE STE 141 <br />Employee ID and Name <br />STOCKTON, CA 95207 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0002422 10180927 <br />Facility Name <br />LINCOLN VILLAGE HOA#3 <br />Location <br />6401 BELMONT PL <br />D <br />STOCKTON, CA 95207 <br />Phone <br />209-956-5660 <br />Mailing Address 1231 W ROBINHOOD DR STE D3 <br />STOCKTON, CA 95207 <br />Care of INTEGRITY ASSOC. MGMT <br />Location Code 99 - UNINCORPORATED A <br />BOS District 002 - MILLER, KATHERINE <br />APN 09707012 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name LINCOLN VILLAGE#3/MURPHY <br />Title <br />Day Phone 209-956-5660 <br />Night Phone 209-644-4900 <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />Account ID AR0007728 New Account ID: : <br />Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br />Account Name LINCOLN VILLAGE HOA #3 (Circle One) <br />Account Balance as of 3/22/2017: $0.00 <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 />Payment Ty a Check Number Received by 2 <br />EHD Staff: Y r \g Date — Account out: Date 3/ "✓ !, <br />COMMENTS: �/► I /� Q �� �,� ,� ,,,,� ; Q <br />I �U LVr `1 �UUI �/IV w1IN���O I � is Invoice #: <br />CQ.U. <br />0 <br />(Circle One) <br />Transfer to <br />Active/Inactve <br />Program/Element and Description <br />Record ID <br />Employee ID and Name <br />Status <br />New Owner? <br />Delete <br />1620 - RETAIL MKT 26-300 SO FT (INCIDENTAL FOODS; <br />PR0518664 <br />EE0006213 - VIDAL PEDRAZA <br />Active <br />Y N <br />A <br />D <br />1921 - HMBP-Regular-Primary Location <br />PR0530834 <br />EE0008709 - JAMIE LIMA <br />Active <br />Y N <br />A <br />I D <br />3116 - STORMWATER INSPECTION - FOOD <br />PR0522856 <br />EE0000149 - RAYMOND BORGES <br />Inactive <br />Y N <br />A <br />D <br />3611 -PUBLIC POOUSPA -PRIMARY <br />PR0360391 <br />EE0006213 - VIDAL PEDRAZA <br />Active <br />Y N <br />A <br />I D <br />3612 - PUBLIC POOL/SPA-ADDITIONAL <br />PR0517409 <br />EE0006213 - VIDAL PEDRAZA <br />Active <br />Y N <br />A <br />I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGE <br />PR0532233 <br />Inactive <br />Y N <br />A <br />I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, <br />PHS/EHD 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 <br />will be performed in accordance with all applicable Ordinance Codes and/or Standards and State andor <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 />Payment Ty a Check Number Received by 2 <br />EHD Staff: Y r \g Date — Account out: Date 3/ "✓ !, <br />COMMENTS: �/► I /� Q �� �,� ,� ,,,,� ; Q <br />I �U LVr `1 �UUI �/IV w1IN���O I � is Invoice #: <br />CQ.U. <br />0 <br />