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Run by : STAFF San Joaquin County PHS/EHD Report #5021 <br /> FACILITY INFORMATION as of 10%24/97 <br /> -------------------------------------------------------------------------------- <br /> OWNER FILE INFORMATION <br /> Make changes/corrections in RED pen or pencil: <br /> INFORMATION CHANGE (date) : <br /> OWNERSHIP CHANGE (date) : <br /> OWNER ID: 001721 New Owner ID: 00 <br /> Owner Name: KAITZ & KAITZ <br /> Owner DBA: COUNTRY HOLLOW APARTMENT SPA <br /> owner Address: 20880 BAKER #9 <br /> CASTRO VALLEY, CA 94546 <br /> Home Phone: <br /> Soc Sec# / Tax ID#: <br /> Ownership Type: 01 CORPORATION <br /> Mailing Address: 20880 BAKER #9 <br /> Care of: COUNTRY HOLLOW APARTMENT SPA <br /> CASTRO VALLEY, CA 94546 <br /> FACILITY FILE INFORMATION <br /> FACILITY ID: 007305 r <br /> Facility Name: COUNTRY HOLLOW APARTMENT <br /> Location: 5858 MORGAN PL <br /> STOCKTON 95219 <br /> Phone: 209-952-2377 <br /> Mailing Address: 20880 BAKER #9 <br /> Care of: COUNTRY HOLLOW APARTMENT SPA <br /> CASTRO VALLEY, CA 94546 <br /> Location Code: 0 1 APN: <br /> BOS District: SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ACCOUNT ID: 0010815 New AccountID: 000 <br /> Mail invoices to: Account Mail Invoices to: Owner / Facility / Account <br /> Account Name: HYGIENETICS ENV SERVICES INC (Circle one) <br /> Account Balance as of 10/2 4/9 7 : $0 . 00 (Circle one) <br /> Record UST(s) Transfer to Activate / Inactivate <br /> P/E Description ID Employee Status Linked new owner? Delete <br /> --------------------------------- -------------------------------------------- <br /> 2950 ENVIRON ASSESS PRS06258 0684 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 <br /> ------------------------------------------------------------------------------- <br /> PR Records to be TRANSFERED: x $20.00 = Amount Paid Date-/-/ <br /> Water System to be TR.ANSFERED: x $150.00 = Amount Paid Date <br /> Payment Type Check # Recvd by <br /> REHS or COUNTER SUPV: Date / / ACCT out: Date-/-/ UNIT/File:-/-/ <br /> i <br />