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Dale run 12/3/2008 2:53:39PK SAN J(' WW COUNTY ENVIRONMENTAL HEA' 9 DEPARTMENT Repod 05021 <br /> Run by �owPagel <br /> Facility Information as of 12/3/20 <br /> Record Selection Criteria: Facility ID FA0009997 <br /> Make changesicorrections in RED Ink or pencil. <br /> INFORMATION CHANGE(date) Z Z <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0007997 Case Number: H06178 New Owner ID <br /> Owner Name GRIFFEN, STEPHEN <br /> Owner DBA COUNTRY CLUB SERVICE <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-474-3141 <br /> Mailing Address 1403 W COUNTRY CLUB BLVD <br /> STOCKTON, CA 95204 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009997 <br /> Facility Name COUNTRY CLUB SERVICE <br /> Location 1403 W COUNTRY CLUB BLVD <br /> STOCKTON, CA 95204 <br /> Phone 209-943-3633 <br /> Mailing Address 1403 W COUNTRY CLUB BLVD <br /> STOCKTON, CA 95204 <br /> Care of <br /> Location Code 99-UNINCORPORATED A Alt Phone <br /> BOS District 002- RUHSTALLER, LARRY Fax <br /> APN 12323246 EMaii: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016997 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name COUNTRY CLUB SERVICE (CirdeOne) <br /> Account Balance as of 12/3/2008: $0.00 <br /> (Cede one) <br /> Transfer to AetNalinamve <br /> ProgramfEteme ut and Description Record ID Employee ID and Name Status New Ownefi Delete <br /> -SM HW GEN<5 TONSNR PRO514125 EE0004636-GARRETT BACKUS Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO512285 EE0000000-HAZ MAT SJC DES Inactive v N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0520012 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPRO509997 EEOOOOOOO-HAZ MAT SJC DES Inactive V N A I D <br /> 3122-STORMWATER INSPECTION-AUTO SHOP PRO522966 EE0004636-GARRETT BACKUS Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned omier.operator or agent of same,aebroeeedge Nal i sue,ardor project Specific.PHS/EHD hourly charges assoaated mth this <br /> IacYsy or adfrily wa W billed to the I�ty idennfied as Ne OWNER on11this farm. I also cari,,+N/Nal as apewtlae we be Performed N amonlante with al apppkaeb Ordinate Codes or Standards and <br /> Side ardor Federal Laws. _Y .Q �C.0 L+ <br /> APPLICANT'SSIGNATURE: <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Receiv <br /> REHS: Date y /� Account out: Date / <br /> COMMENTS: <br /> zo �U 2az� b� k 3q Ft�.S 0 Lj <br /> \\phs-ehsgl-nt\apps\envisions\reports\5021.rpt g ^` /�"- �j[7'!2'7, �ryr.,�G� •"` /1-�ZrdO <br />