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Date run 8/25/2003 1:47:51 PK SAN JOA AW COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 8/25/2003 <br /> Record Selection Criteria: Facility ID FA0014356 <br /> Make changeslcorrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0011407 New Owner ID <br /> Owner Name MILLER, DAVID K& DEBORAH R <br /> Owner DBA MILLER RES. UIC DRUG LAB <br /> Owner Address 24876 N SUTTERFIELD RD <br /> ACAMPO, CA 95220 <br /> Home Phone 209-368-8173 <br /> Work/Business Phone Not Specified <br /> Mailing Address 24876 N SUTTERFIELD RD <br /> ACAMPO, CA 95220 <br /> Care of DAVID & DEBORAH MILLER <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0014356 <br /> Facility Name MILLER RES. UIC DRUG LAB <br /> Location 24876 N SUTTERFIELD RD <br /> ACAMPO, CA 95220 <br /> Phone 209-368-8173 <br /> Mailing Address 24876 N SUTTERFIELD RD <br /> ACAMPO, CA 95220 <br /> Care of DAVID & DEBORAH MILLER <br /> Location Code APN: <br /> BOS District SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0024397 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner I Facility I Account <br /> Account Name MILLER , IC DRUG LAB (circle one) <br /> Account Balance as of 8/25/200 $0.00 <br /> (Circle O <br /> Transfer to getivell etve <br /> Program/Element and Description Record!D Employee ID and Name Status New Owner? Del <br /> 1322-SUBSTANDARD HOUSING-POSTED PRO521313 EE0000369-ALAN BIEDERMANN Inactive y N A(�/i D <br /> 3030-UI CONTROL PROG SITE PRO519201 EE0000684-MICHAEL INFURNA Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site, dlor pro specific,PHSlEHD 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 acco a with all applicable Ordinate Codes andfor Standards and <br /> State andlor Federal Laws, <br /> APPLICANTS SIGNATURE: Date I I <br /> Program Records to be TRANSFEREO: '$20.00 W Amount Paid Date / 1 <br /> Water System to be'1`RANS D: '$155.00= Amount Paid Date 1 I <br /> Payment Type f Check Number Received by <br /> REHS: Date / 10'� Account out: Date / 1 <br /> COMMENTS: <br /> IIPhs-ehsgl-ntlappslEnvisionslReports15021.rpt 4 T <br />