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~Run by� o D • • Report #°5P0A24�1PUBLIAI�� I` SSM CES <br /> ------- _ ___ ------ <br /> SAN N <br /> JOAQUIN COUNTY Make changes/corrections in L r <br /> OWNER FILE INFORMATIdWVIRONMENTAL HEALTH DIVISION INFORMATION CHANGE (date) : <br /> Karen Furst, M.D., M.P.H., Health Officer OWNERSHIP CHANGE (date) : <br /> M <br /> '{G%FERN`• <br /> ��8 East Weber Avenue, Third Floor• Stockton, 9570( <br /> OWNER ID: 0 01 <br /> New Ownerr ID: <br /> Owner Name: ORLANDO, SAM B 209/468-3420 <br /> Owner DHA: <br /> Owner Address: 9725 OAKWILDE AVE <br /> STOCKTON, CA 95212 <br /> Home Phone: 209-931-5146 <br /> Soo Sec# / Tax ID#: <br /> Ownership Type: 01 CORPORATION <br /> Mailing Address: 9725 OAKWILDE AVE <br /> Care of: ORLANDO, SAM B <br /> STOCKTON, CA 95212 <br /> FACILITY FILE INFORMATION �p A <br /> FACILITY ID: 007722 / L'�/Y'W`�/�L./ !ti"L.t•, <br /> Facility Name: ORLANDO' S #3 <br /> Location: 18754 H26 <br /> 95 <br /> LINDEN 95236 <br /> Phone: 209-463-3696 <br /> Mailing Address: 9725 OAKWILD AVE ' <br /> Care of: ORLANDO, SAM & MARILYN <br /> STOCKTON, CA 95212 <br /> Location Code: 99 ABN: <br /> BOS District: SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION I ��jI��I /D: I If ��v ��✓� <br /> ACCOUNT ID: 0013418 �vCL/ ' Ao"count In: �Ol�� <br /> Mail Invoices to: Facility Xt,� / M 1 Inpvo. a to: Owner / Facility / Account <br /> Account Name: ORLANDO' S #3 I �l\�7 �'�'(/ ///�l/']`�\ircle one) <br /> Account Balance as of 09/09/98 : $-288 . 60 �tV '� �� / y ✓l l!/l % (circle one) <br /> Record I� �/ �UST(a) T\rApSt_ex�/to Activate / Inactivate <br /> P/E Description - ID Employee f Status 'nked w owner? ete <br /> ------------------------------------WK-01- 5-0 --�s Lfip , -- -W <br /> 2361 NEW MULTI UST FACILITY PR507164 0008 BRIGGS ACTIVE 3 Y N A I 'D� <br /> 2399 UNIFIED PROGRAM FAC STATE SERV PR307680 0006 } <br /> BRIGGS y11..,,'lQV BCTIV/- I Y <br /> -- --------------------------- -�)ri / <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this form. I also certify that all operations will be performed in accordance with all applicable SAN JOAQUIN <br /> COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> ------------------------------_ _ ___________ _ _________ ______________ <br /> PR Records to be TRANSFERED: x $20.00 Amount Paid <br /> Water System to be TRANSFERED: x $150.00 = Amount Paid Date-/-/- <br /> Payment <br /> ate / /Payment Type Check # Recvd by <br /> ------------------------------------------------------------------------------- <br /> REHS or COUNTER SUPV: Date_/_/ ACCT out: Date-/-/- UNIT/File: / / <br /> Wivision of San Joaquin County Health Carc ScrviA <br />