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Date run 9/19/2011 3:30:28PR SAN JC UIN COUNTY ENVIRONMENTAL HEA I DEPARTMENT Report #5021 <br />Run by - Pagel <br />Facility Information as of 9/19/2011 <br />Record Selection Criteria: Facility ID FA0002453 <br />FACILITY FILE INFORMATION <br />Facility ID <br />17 <br />IN �JlzILM <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0001877 <br />Owner Name <br />ARTHURS PARTY STORE <br />Owner DBA <br />ARTHURS PARTY <br />Owner Address <br />656 ROSEMARIE LN <br />STOCKTON, CA 95207 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-952-2971 <br />Mailing Address <br />PO BOX 519 <br />LODI, CA 95241 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0002453 <br />Facility Name <br />ARTHURS PARTY STORE <br />Location <br />656 ROSEMARIE LN <br />STOCKTON, CA 95207 <br />Phone <br />209-952-2971 x0 <br />Mailing Address PO BOX 519 <br />LODI, CA 95241 <br />Care of <br />Location Code 01 - STOCKTON <br />BOS District <br />APN 11024010 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name ARTHURS PARTY STORE <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0004644 <br />Mail Invoices to Owner <br />Account Name ARTHURS PARTY STORE <br />Account Balance as of 9/19/2011: $0.00 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />--]�J A<��,✓�-r <br />Alt Phone <br />Fax <br />EMail : <br />New Account ID: <br />Mail Invoices to: Owner / <br />Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />dEP <br />1615 - RETAIL MKT 301-2000 SQ FT (PREPKGD/LTPR0160569 EE0003361 - MARIBEL FLOHRSCH Y N A U D <br />2244 - PACT TRANSFER RECORD - OES PR0530816 Active Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHPR0534068 Active 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, 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: <br />Date <br />Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date / 1 <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Tyype� Check Igumber Received ty <br />REHS: unM Date a 1��1� Account out: Date l 1� <br />COMMENTS: <br />2 tit :?,t a�CS Ol �0 m U v -C'&( +3 41 A o i- I~{ V— <br />CDA.-H on — w i (, l 6t- S'-1 Lam, VI q ^— to 53 +4 -p y t -?4- c I C -'a <br />\\eh-env\envision\reports\5021.rpt Ot kAr 1-`P'yy-4 + xh0-f- Y-+* Sc�-i ✓td <br />