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Date run 6/1/2005 2:52:59PM SAN JC UIN COUNTY ENVIRONMENTAL HEA l DEPARTMENT Report#5021 Run by Pagel Facility Information as of 6/1/2005 Record Selection Criteria: Facility ID FA0015509 Make changes/corrections in RED ink or pencil. INFORMATION CHANGE(date) OWNERSHIP CHANGE(date) OWNER FILE INFORMATION Owner ID OW0001692 New Owner ID Owner Name PATEL, GIRISHKUMAR K Owner DBA Owner Address 5708 N HWY 99 STOCKTON, CA 95212 Home Phone 209-931-3341 Work/Business Phone Not Specified Mailing Address 5708 N HWY 99 STOCKTON, CA 95212 Care of PATEL, GIRISHKUMAR K FACILITY FILE INFORMATION Facility ID FA0015509 Facility Name ST FRANCIS MOTEL Location 5708 N HWY 99 STOCKTON, CA 95212 Phone 209-931-3341 Mailing Address 5708 N HWY 99 STOCKTON, CA 95212 Care of Location Code 99 - UNINCORPORATED AREA APN:08703013 BOS District 003 - MOW, VICTOR SIC Code: ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0026781 New Account ID: Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account Account Name ST FRANCIS MOTEL (Circle One) Account Balance as of 6/1/2005: $111.60 (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 3030-UIC PROGRAM SITE PR0522753 EE0000684-MICHAEL INFURNA Active Y N A I D 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 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 Ordinate Codes and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: *$20.00= Amount Paid Date Water System to be TRANSFERED: *$155.00= Amount Paid Date Payment Type Check Number Received by RENS: Date / ! Account out: Date COMMENTS: \\phs-ehsql-nt\apps\envisions\reports\5021.rpt