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Date run 10/11/2005 9:27:31A SAN JOA TN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5027 <br /> Run by +'�►' <br /> Facility Information as of 10/11/2005 Page <br /> Record Selection Criteria: Facility ID FA0015420 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0010551 New Owner ID <br /> Owner Name GREEN, CHARLES <br /> Owner DBA WALNUT ST MEDICAL CENTER <br /> Owner Address 4125 ST ANDREWS DR <br /> STOCKTON, CA 95219 <br /> Home Phone 209-466-2381 <br /> Work/Business Phone Not Specified <br /> Mailing Address 1617 N CALIFORNIA ST <br /> STOCKTON, CA 95204 <br /> Care of GREEN, CHARLES <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0015420 <br /> Facility Name CALIFORNIA STREET MEDICAL BLDG <br /> Location 1617 N CALIFORNIA ST <br /> STOCKTON, CA 95204 <br /> Phone 209-948-6435 <br /> Mailing Address 1610 N EL DORADO ST <br /> STOCKTON, CA 95204 <br /> Care of GREEN, CHARLES <br /> Location Code 01 -STOCKTON APN:12715050 <br /> BOS District 002 - MARENCO, DARIO SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0026589 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name CALIFORNIA S REET MEDICAL BLDG (Circle One) <br /> Account Balance as of 10/11/2005: $0 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PR0522629 EE0000684-MICHAEL INFURNA Ac' e Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/ project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: *$372.00= Amount Paid Date <br /> Payment Type Check Number Received <br /> REHS: Date Account out: Date / Len=., <br /> COMMENTS: <br /> \\phs-ehsq I-nt\apps\envisions\reports\5021.rpt <br />