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Run by LAURIEB Sawn Joaquin County PHS/EHD Report #5021 <br /> FACILITY INFORMATION as of 03/25/97 <br /> Make changes/corrections in RED pen or pencil: <br /> OWNER FILE INFORMATION INFORMATION CHANGE (date): <br /> OWNERSHIP CHANGE (date): <br /> OWNER ID: 004559 New Owner ID: 00 <br /> Owner Name: DELPH, WILBUR <br /> Owner DBA: MORADA VETERINARY CLINIC <br /> Owner Address: 9629 N HWY 99 <br /> STOCKTON, CA 95212 <br /> Home Phone: 209-931-4117 <br /> Soc Sec# / Tax ID#: <br /> Ownership Type: 01 CORPORATION <br /> Mai l i ng Address: 9629 N HWY 99 <br /> care of: DELPH, WILBUR <br /> STOCKTON, CA 95212 <br /> FACILITY FILE INFORMATION <br /> FACILITY ID: 005748 <br /> Facility Name: MORADA VETERINARY CLINIC <br /> Location: 9629 N HWY 99 <br /> STOCKTON 95212 <br /> Phone: 209-931-1874 <br /> Mailing Address: 9629 N HWY 99 <br /> care of: DELPH, WILBUR <br /> STOCKTON, CA 95212 Ko ; <br /> Location Code: APN: J�fl/� 'a - <br /> BOS District: SIC Code: MA R 2 5 1997 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION pujaL <br /> SAN JOAOurN 000NTy <br /> _ ENVf�RQ�M�Nrp� NEA 6;�VICES <br /> ACCOUNT ID: 0006445 6117, 4L-Account ID:1N,[�� <br /> Mail Invoices to: Owner Mail Invoices to:- Owner / FaciftV� / Account <br /> Account Name: DELPH, WILBUR .. (Circle one) <br /> Account Balance as of 03/25/97: $0 . 00 e) <br /> Record ' UST(s) Transfer to fZetel <br /> nactivate <br /> P/E Description ID Employee tatus Linked- new owner? <br /> 2951 UGT-CAP PR503256 0001 TURKATTE INACTIVE'' Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, erato? or agent of same, acknowledge that all site and/or <br /> project specific PHS/EHD hourly charges associated with this facili activilty 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 A 390 Date 3 / 5 / 7 <br /> Water System to be TRANSFERED: x $150.00 = Amount Paid Date <br /> Payment Type Check # /710 Recvd by <br /> - <br /> REHS or COUNTER SUPV: Date / / ACCT out: Date 0 <br />