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Report # 5021 <br /> Run by STAFF San Joaquin County PHS/EHD '� Re P <br /> I-"- <br /> FACILITY INFORMATION as of 10,/24 <br /> -------- -------------------------- <br /> 1 Make changes/corrections in RED pen or pencil: <br /> OWNER FILE INFORMATION INFORMATION CHANGE (date) : <br /> OWNERSHIP CHANGE (date) : <br /> OWNER ID: 005982 New owner;ID: 00 <br /> Owner Name: FLORSHEIM BROTHERS <br /> owner DBA: FLORSHEIM HOMES I ) <br /> Owner Address: 1701 W MARCH LN #D I <br /> STOCKTON, CA 95207 I! <br /> Home Phone; 209-473-1106 <br /> Soc Sec# / Tax ID#: <br /> Ownership Type: 01 CORPORATION I ! <br /> Mailing Address: 1701 W MARCH LN #D j <br /> k Care of: FLORSHEIM BROTHERS <br /> l STOCKTON, CA 95207 11 <br /> FACILITY FILE INFORMATION �l <br /> I� <br /> FACILITY ID: 007262 ' <br /> Facility Name: FLORSHEIM HOMES <br /> Location: AUTUMN CHASE CIR <br /> STOCKTON 95219 <br /> Phone: 209-473-1106 <br /> Mailing Address: 1701 W MARCH LN #D 1. + <br /> care of: FLORSHEIM BROTHERS I! <br /> STOCKTON, CA 95207 I <br /> Location Code: 01 APN: <br /> BOS District: SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION �f <br /> ACCOUNT ID: 0010697 New Account ID 000 <br /> Mail Invoices to: Account Mail Invoices to: Owner / Facility / Account <br /> Account Name: GRUPE DEVELOPMENT ASSOC-2 (Circle one) <br /> Account Balance as of 10/24/9 7 : $0 . 00 (Circle one) <br /> Record LT(s) J <br /> Transfer to Activate / Inactivate <br /> P/E Description ID --- Employee--------Status ILinked' new owner? Delete <br /> -------------------------- --------------------------------- <br /> r I <br /> 2953 LCL HW CLEANUP SITE PR50619D 0664 INFURNA INACTIVE } 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 <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 111 <br /> ---------------------------------------------------- ------- - ------------------ <br /> PR Records to be TRANSFERED: x $20.00 = Amount Paid!� Date <br /> Water System to be TRANSFERED; x $150.00 = Amount Paid I Date <br /> 3 <br /> Payment Type Check # I'r Recvd by <br /> REHS or COUNTER SUPV: Date / / ACCT out: Date 'P/ / UNIT/File: <br /> I <br />