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Date run 7/26/2004 10:08:04AI SAN'OAQUIN COUNTY ENVIRONMENTAL HEAT TH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/26/_..;4 <br /> Record Selection Criteria: Facility ID FA0000208 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0000169 New Owner ID <br /> Owner Name NEWPORT PACIFIC CAPITAL CO <br /> Owner DBA ARBOR MOBILE HOME PARK <br /> Owner Address 17300 RED HILL AVE 280 <br /> IRVINE, CA 92714 <br /> Home Phone 209-369-2452 <br /> Work/Business Phone 714-852-5575 <br /> Mailing Address 17300 RED HILL AVE#280 <br /> IRVINE, CA 92714 <br /> Care of NEWPORT PACIFIC CAPITAL <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0000208 <br /> Facility Name ARBOR MOBILE HOME PARK <br /> Location 19690 N HWY 99 <br /> ACAMPO, CA 95220 <br /> Phone 800-339-6722 <br /> Mailing Address 871 38TH AVE <br /> SANTA CRUZ, CA 95062 <br /> Care of EMS <br /> Location Code 99 - UNINCORPORATED AREA APN:01708053 <br /> BOS District 004 -SEIGLOCK, JACK SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000207 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name ARBOR MOBILE HOME PARK (Circle One) <br /> Account Balance as of 7/26/2004: $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 /> 3611 -PUBLIC POOUSPA-PRIMARY PR0360004 EE0003027-MINH NGUYEN Active Y N A I D <br /> 3612-PUBLIC POOUSPA-ADDITIONAL PR0360191 EE0003027-MINH NGUYEN Active Y N A I D <br /> 4242-WASTE WATER TX PLANT PR0420602 EE0005366-LISA MEDINA Active Y N A I D <br /> 4643-100-199 SERVICE CONNECTIONS(CWS)WWA0460831 EE0000753-WILLIE NG 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: *$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 />