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Date run 8/19/2003 11:29:18AI SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/19/2003 <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 1 Facility / Account <br /> Account Name MILLER RES. UIC DRUG LAB (Circle One) <br /> Account Balance as of 811912003: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1322-SUBSTANDARD HOUSING-POSTED PR0521313 EE0000369-ALAN SIEDERMANN Inactive Y N A I D <br /> 3030-Ul 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,and/or project 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 accordance with all applicable Ordinate Codes arWor Standards and <br /> State and/or Federal Laws, <br /> APPLICANT'S SIGNATURE: Date I 1 <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date 1 ! <br /> Water System to be TRANSFERED: *$155.00= Amount Paid Date 1 I <br /> Payment Type Check Number Received by <br /> RENS: Date I I Account out: Date 1 1 <br /> COMMENTS: <br /> 11Phs-ehsgl-ntlappslEnvisionslRepotts15021.rpt *0W ` W <br />