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Date run 6/1/01 12:08:38PM SAQUIN COUNTY PUBLIC HEALTH SES Report #: 0002 <br /> Run by Facility Information as of 6/1/01 ISE Page #: 1 <br /> Record Selection Criteria: Facility ID FA0012730 I1 <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 to: OW0009916 New Owner ID <br /> Owner Name: CAMPBELL, MIKE <br /> Owner DBA: <br /> Owner Address; 13000 E TEMPLE AVE <br /> CITY OF INDUSTRY, CA 91746- <br /> Home Phone: 209-983-4999 <br /> Work/Bussness Phone• Not Specified <br /> Mailing Address: 13000 E TEMPLE AVE <br /> CITY OF INDUSTRY, CA 91746- <br /> Cam of: CAMPBELL, MIKE <br /> FACILITY FILE INFORMATION <br /> Facility to: FA0012730 <br /> Facility Name: MIKE CAMPBELL &ASSOCIATES LTD <br /> Location: 781 SWIFT WAY <br /> STOCKTON, CA 95206 <br /> Phone: 209-983-4999 r L' <br /> Mailing Address: 13 <br /> 000 p , <br /> (�� 0 I I I1 p <br /> Care of: MIKE CAMPBELL <br /> Location Code: APN; <br /> BOS District SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0021248 New Account ID:: <br /> Maulnvoicesto: Facility Mail Invoices to: Owner/Facility/Account <br /> Account Name: MIKE CAMPBELL &ASSOCIATES LTD (Circle One) <br /> Account Balance as of 6/1/01: $0.00 <br /> (Circle One) <br /> UST(s) Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status Linked New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0516666 EE0000418-KITH Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE F PR0516667 EE0000418-KITH Active Y N A 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 or activity will be billed to the party identified as the BILLING PARTY on this form. I also certify that all <br /> operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I I <br /> Program Records to be TRANSFERED: '$0.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$150.00= Amount Paid Date <br /> Payment T pe Check Number Receipt Number Received by <br /> REHS: Date / / Account out: Date <br /> UUMMEIN IV <br /> 1.0.0.89.00 • <br />