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D; un I $/21/2013 10:30:59AI SAN JOAN COUNTY ENVIRONMENTAL HEAL'OEPARTMENT Report#5021 <br /> RU y Pagel <br /> Facility Information as of 8/21/2013 <br /> Record Selection Criteria: Facility ID FA0016065 <br /> Make changesfcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0016653 New Owner ID <br /> Owner Name OAKWOOD LT VENTURES II LLC <br /> Owner DBA OAKWOOD SHORES <br /> owner Address 5000 EXECUTIVE PKWY#530 <br /> SAN RAMON, CA 94583 k' <br /> Home Phone 925-355-1305 <br /> Work/Business Phone Not Specified <br /> Mailing Address 5000 EXECUTIVE PKWY #530 <br /> SAN RAMON, CA 94583 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0016065 <br /> Facility Name OAKWOOD SHORES <br /> Location 1699 BELLA LAGO WAY <br /> MANTECA, CA 95337 <br /> Phone <br /> Mailing Address 5000 EXECUTIVE PKWY #530 <br /> SAN RAMON, CA 94583 <br /> Care of OAKWOOD LT VENTURES II LLC <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> Bos District 005- ELLIOTT, BOB Fax <br /> APN 24152013 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name OAKWOOD LT VENTURES II LLC <br /> Title <br /> Day Phone 925-355-1305 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0028034 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name OAKWOOD SHORES (Circle One) <br /> Account Balance as of 8/21/2013: <br /> (Circle One) <br /> Transfer to Activellnactve <br /> PmgramiElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2965-WATER QUALITY SITE PROJECT PR0523856 EE0000997-HARLIN KNOLL Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as Me OWNER on this torn I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Laws <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date_/ / Account out: Date <br /> COMMENTS: <br />