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Date run 9/14/2004 11:45:43AI SAN JOAQUIN COUNTY ENVIRONMENTAL HETH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9/14/ 4 <br /> Record Selection Criteria:, Facility ID FA0004502 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> Owner ID OW0003417 New Owner ID <br /> Owner Name NORMAN, CHARLES <br /> Owner DBA NORMAN'S NURSERY <br /> Owner Address 8665 E DUARTE ROAD <br /> SAN GABRIEL, CA 91775 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-772-1823 <br /> Mailing Address 8665 E DUARTE ROAD <br /> SAN GABRIEL, CA 91775 <br /> Care of CHARLES NORMAN <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0004502 <br /> Facility Name NORMAN'S NURSERY <br /> Location 6250 ESCALON BELLOTA ROAD <br /> LINDEN, CA 95236 <br /> Phone <br /> Mailing Address 8665 E DUARTE ROAD <br /> SAN GABRIEL, CA 91775 <br /> Care of CHARLES NORMAN <br /> Location Code 99- UNINCORPORATED AREA APN:WC <br /> BOS District 004-SEIGLOCK, JACK SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0004184 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name NORMAN'S NURSERY (Circle One) <br /> Account Balance as of 9/14/2004: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4630-NTNC WATER SYSTEM WA0461345 EE0000753-WILLIE NG Active Y N A I D <br /> 2',91 <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 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: *$155.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\phs-ehsql-nt\apps\envisions\reports\5021.rpt <br />