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Date run 10/22/2009 2:00:03F SAN JC UIN COUNTY ENVIRONMENTAL HEA I DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/22/2009 <br /> Record Selection Criteria: Facility ID FA0015782 <br /> N 11111111011111 Make changes/corrections in RED ink. <br /> IN F'j <br /> F16 wine INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) 107-2i7(I <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0012710 New Owner ID : <br /> Owner Name SEVENTH DAY ADVENTISTS CHURCH Ar-5-5/e yOdNb <br /> Owner DBA <br /> Owner Address 2962 S B ST <br /> STOCKTON, CA 95206 66- <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 2962 S B ST L9 <br /> STOCKTON, CA 95206 BUJ E "17S l�VE• <br /> Care of SEVENTH DAY ADVENTISTS CHURCH , -30C (ZsgAl e �,0 95WS <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0015782 <br /> Facility Name SEVENTH DAY ADVENTISTS CHURCH $SSS/E yo1/AI(� <br /> Location 2962 S B ST <br /> STOCKTON, CA 95206 <br /> Phone <br /> Mailing Address 2962 S B ST <br /> STOCKTON, CA 95206 ✓704c740y C49- !f S-Aos <br /> Care of SEVENTH DAY ADVENTISTS CHURCH P"ORItH SYRO <br /> Location Code 99 - UNINCORPORATED A Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 17119029 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name ✓��/tel�/ v�i`p <br /> Title .4o >� <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0027355 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name SEVENTH DAY ADVENTISTS CHURCH (Circle One) <br /> Account Balance as of 10/22/2009: $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 /> 1322-SUBSTANDARD HOUSING-POSTED PR0523358 EE0002424-ROCHELLE VELOSO-C/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 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: *$372.00= Amount Paid Date <br /> Payment TypeCheck Number Receiv d b <br /> REHS: Date 119 / 7/7'—/ Account out: Date Z 3 <br /> COMMENTS: <br /> C* new nw►�rt' <br /> \\eh-env\envision\reports\5021.rpt <br />