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Report <br /> Date run 3/25/2011 3:03:53Pk SAN JON COUNTY ENVIRONMENTAL HEA EPARTMENT #5021— <br /> Pagel <br /> Run by Facility Information as of 3/25.201 <br /> Record Selection cmena: Facility ID FA0004043 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION "Oft"�ii—� SSN I Fed Tax ID <br /> Owner ID OW 0002972 New Owner ID <br /> Owner Name KIRK, EDWARD B <br /> owner DBA AKF DEVELOPMENT LLC <br /> Owner Address 1132 NORMAN DR <br /> MANTECA, CA 95336 <br /> Home Phone 209-823-3121 <br /> Work/Business Phone Not Specified <br /> Mailing Address 1132 NORMAN DR <br /> MANTECA, CA 95336 <br /> Care of KIRK, BING <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0004043 <br /> Facility Name SPRECKLES BUSINESS PARK <br /> Location 18800 S SPRECKELS RD <br /> MANTECA, CA 95336 <br /> Phone 209-823-3121 <br /> Mailing Address 1132 NORMAN DR <br /> MANTECA, CA 95336 <br /> Care of BING KIRK <br /> Location Code 04- MANTECA Alt Phone <br /> BOS District 005-ORNELLAS, LEROY Fax <br /> EMail <br /> APN <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name BING KIRK <br /> Title <br /> Day Phone 209-603-8292 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> New Account ID: <br /> Account ID AR0003687 <br /> Mail Invoices to Account Mail Invoices to: Owner I Facility I Account <br /> (Circle One) <br /> Account Name AFK DEVELOPMENT LLC <br /> Account Balance as of 3125/2011: $-244.00INK"', <br /> _ „wTI ire (Circle One) <br /> IV^" Transfer to Activellnaclve <br /> Program/Element and Description Record ID Employee ID and Name <br /> Status New Owner? Delete <br /> 2960-RWOCB SITE <br /> PR0009289 EE0000684-MICHAEL INFURNA A e Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, <br /> the undersigned owner,operator or agent of same,acknowledge that all site,andlor 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. 1 also certify That all operations will be performed in accordance with all applicable Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. 1 <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to b ANSF ED: <br /> Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date _/z5 / ( Account out: — Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />