Laserfiche WebLink
Date run : ]/10/01 12:28:38PM SA! ')AQUIN COUNTY PUBLIC HEALTH SE.,,.,CES Report #: 0002 <br /> Run by LBROWN Facility Information as of 1/10/01 Page #: 1 <br /> Record Selection Criteria: FacilityID FA0009311 <br /> Record ID <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE (date) <br /> OWNERSHIP CHANGE (date) <br /> OWNER FILE INFORMATION <br /> Owner ID: OW0007311 Case Number: H03037 New Owner ID <br /> Owner Name: ROGER KARLSRUD <br /> Owner DBA: WESPRINT <br /> Owner Address: <br /> Home Phone: Not Specified <br /> Work/Bussness Phone: 209-465-2615 <br /> Mailing Address: 4101 ARCH RD <br /> Care of: <br /> FACILITY FILE INFORMATION <br /> Facility to: FA0009311 N n n <br /> Facility Name: WESPRINT <br /> Location: 4101 ARCH RD <br /> STOCKTON, CA 95215 20 <br /> Phone: 209-465-400400 0VU <br /> (ll�l. T f� `FOit�"S(YJINuGI <br /> Mailing Address: PO BOX 30757 <br /> STOCKTON, CA 95213- <br /> care of: ROGER KARLSRUD <br /> Location Code: 01 - STOCKTON APN; 29968-8 <br /> BOS District: 004-SEIGLOCK, JACK SIC Code; <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0016311 New Account ID:: <br /> Mail Invoices to: Owner Mail Invoices to: Owner/Facility/Account <br /> Account Name: ROGER KARLSRUD (Circle One) <br /> Account Balance as of 1/10/01: $666.30 <br /> (Circle One <br /> UST(s) Transfer to Active/Inactv <br /> Program/Element and Description Record ID Employee ID and Name Status Linked New Owner? e <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE F PR0509311 EE0000000-SJC DES Active Y N <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0511599 EEe000000-SJC DES Active Y N <br /> 2220-SM HW GEN<5 TONSNR PR0513765 EE0007289-YOUNGBLOOD Active Y N I <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent a/'same,acknowled a that aUsite,arrd/orpro'ect <br /> specific,PRSIERD hourly charges associated with this factGty or activity will be billed to the party ulentTfred as the B/CLING PARTYon thisjorm. I <br /> also certify that all operations will be performed in accordance with all applicable Ordinate Codes and/or Standards and State and/or Federal Laws <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: "$0.00= Amount Paid Date / / <br /> Water System to be TRANSFERED: '$150.00= Amount Paid Date <br /> Payment Type Check Number Receipt Number Received by <br /> REHS: Date / / Account out: Date <br /> UUMMLN 15. <br /> 1.0.0.89.00 <br />