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Report#15021 <br /> E <br /> /14/2003 8;02:;53AN SAN JOIN COUNTY ENVIRONMENTAL HE DEPARTMENT Pagel <br /> Facilit Information as of 5/14/2Yn Criteria: D FA0012756 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0009938 New Owner ID <br /> Owner Name ELKS LODGE <br /> Owner DBA <br /> Owner Address 317 S CENTER <br /> STOCKTON, CA 95202 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 317 S CENTER <br /> STOCKTON, CA 95202 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012756 <br /> Facility Name ELKS LODGE PROPERTY <br /> Location 317 S CENTER <br /> STOCKTON, CA 95202 <br /> Phone <br /> Mailing Address 317 S CENTER <br /> STOCKTON, CA 95202 <br /> Care of <br /> Location Code APN: <br /> BOS District SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0021321 New Account ID: <br /> Mail Invoices to: Owner / Facility / Account <br /> Mail Invoices to Account <br /> (Circle One) <br /> Account Name DOUGHf- , KEVIN <br /> Account Balance as of 5/14/2003: $0.00 (Circle o <br /> Transfer to Activ nactve <br /> New Owner? De <br /> Program/Element and Description <br /> Record ID Employee ID and Name Status <br /> 2950-ENVIRON ASSESS PRO516724 EE0000684-MICHAEL INFURNA 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,PHS/EHD hourly charges associated wlth 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: $155.00= Amount Paid e iL <br /> Payment TypeCheck Number e' d by REHS: Date / / Account out: Date / <br /> COMMENTS: <br /> \\Phs-ehsq I-n t\apps\E nvisi ons\Re ports\5021.rpt <br />