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Date run 5/16/01 1:47:07PM SAN QUIN COUNTY PUBLIC HEALTH SER' ?S Report #: 0002 <br /> Run by Facility Information as of 5/16/01 Page #: 1 <br /> Record Selection Criteria: Facility ID FA0012098 <br /> Record ID <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE (date) <br /> OWNERSHIP CHANGE (date) <br /> OWNER FILE INFORMATION <br /> Owner ID: OW0009381 New Owner ID <br /> Owner Name: BRAUSE, SUE <br /> Owner DBA: CITY OF STOCKTON <br /> Owner Address: 305 N EL DORADO ST <br /> STOCKTON, CA 95202- <br /> Home Phone: 209-957-8840 <br /> Work/Bussness Phone: Not Specified <br /> Mailing Address: 305 N EL DORADO ST <br /> STOCKTON, CA 95202- <br /> Care of: BRAUSE, SUE <br /> FACILITY FILE INFORMATION <br /> Facility ID: FA0012098 <br /> Facility Name: PROPOSED ESSENTIAL SERVICE FACIL <br /> Location: 22 WEBER AVE <br /> STOCKTON, CA 95202 <br /> Phone• <br /> Mailing Address: 305 N EL DORADO ST <br /> STOCKTON, CA 95202- <br /> Care of: SUE BRAUSE <br /> Location Code: 01 - STOCKTON APN; <br /> Bos District: 001 - GUTIERREZ, STEVE SIC Code; <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0019357 New Account ID:: <br /> Mail Invoices to: Owner Mail Invoices to: Owner/Facility/Account <br /> Account Name: BRAUSE, SUE (Circle One) <br /> Account Balance as of 5/16/01: $0.00 <br /> (Circle One) <br /> UST(s) Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name S1@1tus Linked New Owner? Delete <br /> 2950-ENVIRON ASSESS PR0515352 EE0000684-INFURNA Acti Y IN I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific, <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on this form. I also certify that all <br /> operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$0.00= Amount Paid Date <br /> Water System to be NS RED: '$150.00= Amount Paid Date <br /> Payment Type Check Number Receipt Number Received by <br /> REHS: Date / leo/ D Account out: Date <br /> UUMMEN 16: <br /> 1.0.0.89.00 <br />