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Run by : STAFF (� <br /> , <br /> San Joaquin County pHS/EHD <br /> --------------------FACILITY- INFORMATION as of 02!/04/98 Report #5021 <br /> - ------------ ------ 1 <br /> OWNER -^_'_'-----`--------- k <br /> FILE INFORMATION Make changes/corrections in RED <br /> ' ( pen or pencil: <br /> INFORMATION CHANGE (date) ; <br /> OWNERSHIP CHANGE (date) : <br /> OWNER ID: 005891 q <br /> owner Name: KING ISLAND TRLR PARK & REC CO New owner ID: QQ <br /> Owner DBA: KING ISLAND RESORT & HOLIDAY H ) <br /> Owner Address: PO BOX 1461 '¢ <br /> STOCKTON, CA 95201 } <br /> Home)Phone: 209-465-5883 t <br /> SOC Sec# / Tax ID#: <br /> Ownership Type: 01 CORPORATION <br /> 'i <br /> Mailing Address: <br /> Care of: <br /> 95201 6..„ <br /> FACILITY FILE INFORMATION <br /> FACILITY ID: 007171 <br /> Facility Name: HOLIDAY HARBOR/INTREPID MARINE :p <br /> Location: 11540 W EIGHT MILE RD <br /> STOCKTON 95219 , <br /> Phone: 209-951-2169 <br /> Mailing Address: Z6 . <br /> Care of: < .0 2- <br /> 4 6 —,16 <br /> / i <br /> Location Code: 9 9 APN: ti <br /> BOS District: SIC Code: f <br /> f <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ACCOUNT ID: 0010431 L/ � New Account!ID: 000 <br /> Mail Invoices to: A��B 7�+ � Mail Invoices to: Owner '-,/ Facility Account <br /> Account Name: TOWER PARK MARINA ' {Circle o <br /> Account Balance as of 02/04/98 : $85 . 80 Pd ZIP117 (Circle one) <br /> �.— Record — USTlls) Transfer to Activate Inactivate <br /> a <br /> P/E Description ID Employee Status Linked new owner? Delete <br /> ----------------------------------------- <br /> tg <br /> 2950 ENVIRON ASSESS PR506051 0694 INFURNA ACTIVE ;I YN A I D <br /> -----------------------------7--------------------- <br /> - <br /> -------------------i------------ <br /> - --------------- <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> i <br /> project specific PHS/EHD hourly charges associated with this facility or activity wE ill be billed to the party identified as the <br /> , <br /> BILLING PARTY on this form. I also certify that all operations will be performed in accordance with all applicable SAN JOAQUIN r <br /> COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. I ) <br /> APPLICANT'S SIGNATURE: r4 Date <br /> ------------------------------- --- ----------------------- ------- --------------- xJ <br /> PR Records to be TRANSFERED: x $20.00 Amount Paid f Date <br /> Water System to be TRANSFERED: x $150.00 = Amount Paid '. Date <br /> Payment Type Check # I Recvd by <br /> ---------- _----- --- --- ________________ ----=----- --- <br /> Y / // U ACCT out; l Data z /� / 1 UNIT/File: 4 <br /> REHS or COUNTER SUPV: Date / / <br /> rte- <br />