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Date run 6/30/2004 2:49:07PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 6/30/2004 <br /> Record Selection Criteria: Facility ID FA0015447 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0012402 New Owner ID <br /> Owner Name CORT, DANIEL <br /> Owner DBA CDS INVESTORS PARTNERSHIP _ <br /> Owner Address 343 E MAIN ST <br /> STOCKTON, CA 95202 <br /> Home Phone 209-235-5231 �'-• D <br /> Work/Business Phone Not Specified <br /> Mailing Address 343 E MAIN ST = <br /> STOCKTON, CA 95202 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> (3oto�� <br /> Facility ID FA0015447 /JS/� Q p 6 -7 0o)1/ <br /> Facility Name STOCKTON ROYAL THEATRE <br /> Location <br /> 1825 PACIFIC AVE <br /> STOCKTON, CA 95204 2, <br /> Phone _ b� . . 3Q C t'o) <br /> Mailing Address 1825 PACIFIC AVE <br /> STOCKTON, CA 95204 <br /> Care of DANIEL CORT <br /> Location Code 01 - STOCKTON APN:13702042 <br /> BOS District 002 - MARENCO, DARIO SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0026653 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility ! Account <br /> Account Name STOCKTON WORSHIP CENTER (Circle One) <br /> Account Balance as of 6/30/2004: $-279.00 <br /> 66 (Circle One) <br /> Transfer to Active/Inactve <br /> New Owner? Delete <br /> Program/Element and Description Record ID Employee ID 7d Name Status <br /> '-1 <br /> 2950-ENVIRON ASSESS PR0522666 EE000 42-MARG ET LAGORIO Acts e Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and;r 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 I Check Number Received by <br /> REHS: Date / U l` Account out: Date ! / <br /> COMMENTS: A / <br /> "Z' <br /> LU - ------- <br /> s� <br /> \\Phs-ehsgl-nt\apps\Envisions\Reports\5021.rpty e�'r j�/C t0 w� <br /> v <br />