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Date run ,1611312006 12:24:19PI SAN JOA(&��1 COUNT;ENVIRONMENTAL HEALT,,,...eEPARTMENT Report#5021 <br /> R Pagel <br /> Facility Information as of 6/13/2005 <br /> r <br /> Record Selection Criteria: Facility ID FA0002308 1 <br /> Make changestcorrections in RED Ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> 1. OWNER FILE INFORMATION <br /> Owner ID OW0001782 New Owner ID <br /> Owner Name (4TiI'p�l. �.i "_ <br /> Owner DBA <br /> Owner Address � ILTCfT�T t <br /> CA 148 <br /> Home Phone _g8=23$=5695 v <br /> WorlclBusiness Phone14 <br /> -29u3 <br /> I <br /> Mailing Address- 6 t CE` TCT -e l!t " <br /> --SAN—98E;-£A�=95 Q, <br /> Care ot-RfG}RD(ps$3H-ELEN S-QUIVEL <br /> FACILITY FILE INFORMATION S S'� 5�7� 3 —5770 <br /> Facility ID FA0002308 <br /> Facility Name COUNTRY SQUIRE MOBILE ESTATES <br /> Location 4350 CHEROKEE RD <br /> STOCKTON, CA 95215 <br /> Phone 209-931-2983 <br /> Mailing Address 45941\&EL=fOf!Nfi�--T (9 <br /> Care of PI.GAgD. L SLfi <br /> Location Code 99 - UNINCORPORATED AREA AP 8709016 <br /> ' BOS District 002 - MARENCO, DARIO SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002321 New Acco <br /> Mail Invoices to Facility Mail Invoices to: Owner Facility ! Account <br /> j Account Name COUNTRY SQUIRE MOBILE ESTATES (Circle One) <br /> Account Balance as of 611 312 0 0 5: $947.00 <br /> (Circle one) <br /> Transfer to Activellnactve <br /> Np <br /> Program/Element and Description Record ID Employee ID and Name Status Owner? Delete <br /> 3611 -PUBLIC POOUSPA-PRIMARY PR0360336 EE0006213-VIDAL PEDRAZA Active Y N A I D <br /> 4242-WASTE WATER TX PLANT PR042GO67 EE0005944-MICHAEL ESCOTTO Active Y N A 1 D <br /> 4622-25-99 SERVICE CONNECTIONS(CWS) WA0460607 EE0005838-ADRIENNE ELLSAESSEActive Y N A I A <br /> 5ILLtNG and COMPLIANCE ACKNOWLEDGEMENT: i,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSIEHD 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 andlor Standards and <br /> State andlor Federal Laws. <br /> APPLICANT'S SIGNATURE: _ Date 1� <br /> Program Records to be'T-RANSFERLi "$20.00= Amaunt Paid q&,7. <br /> Date ! 1 <br /> Water System to be TRANSF,ERED: $372.00= Amount Paid Date <br /> !31 0 <br /> Payment T ✓ m �3 Received by <br /> RENS: Date 1 Account out: Date 11 <br /> COMMENTS: <br /> 12 <br /> /3 fay <br /> RECEIVED <br /> JUN 13 20LI i <br /> SAN JOAQUIN cowTy ; <br /> ENVIRONMENTAL <br /> Ilphs-ehsgl-ntlappslenvisionslreports15021.rpt HEALTH DEPARTMENT <br />