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Date run 5/1412003 8:05:49AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by r. a� Pagel <br /> Facility Information as of 5/14/2003 <br /> Record Selection Criteria: Facility ID FA0014356 <br /> Make changes/corrections 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 /> WorklBusiness 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 /> BIDS District SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0024397 New Account ID-- <br /> Mail <br /> D:Mail Invoices to Facility Mail Invoices to: Owner 1 Facility I Account <br /> Account Name MILLER ES:i�tC G LAB (Circle One) <br /> Account Balance as of 5/14/2003: $1 U <br /> (Circle One) <br /> Q•� Transfer to Activellnattve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner Delete <br /> 1322-SUBSTANDARD HOUSING-POSTED PR0521313 EE0000369-ALAN BIEDERMANN Active Y N AD <br /> 3030-UI CONTROL FROG SITE PR0519201 EE0000684-MICHAEL INFURNA Active Y N A E D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSIEHD hourly charges associ with this <br /> facility or activity wfll be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with al!applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I I <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid eDWater System to be TRANSFERED: *$155.00= Amount PaidPayment Type Check Number i <br /> REHS: Date s I / I b 3 Account out: 11f Date Z> /r/ <br /> COMMENTS: <br /> 11Phs-ehsql-ntlappslEnvisionslReports15021.rpt S01 �.� <br />