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Date run 6/6/2008 4:40:26PM SAN JOA 'IN COUNTY ENVIRONMENTAL HEALT11 DEPARTMENT Report 95021 <br /> Run by 4006Pagel <br /> Facility Information as of 6161200b•we <br /> Record Selection C4ted& Facility ID FA0000159 ' <br /> Make changeslcorrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN I Fed Tax ID <br /> Owner ID OW0000135 New Owner ID <br /> Owner Name STINSON, ROBERT <br /> Owner DBA <br /> Owner Address PO BOX 1306 <br /> POULSBO, WA 98370 <br /> Home Phone 520-299-8245 <br /> Work/Business Phone 602-299-8075 <br /> Mailing Address PO BOX 13G06D (p3 <br /> Nq Ar 3 b <br /> Care of STINSON, ROBERT <br /> FACILITY FILE INFORMATION <br /> Facility iD FA0000159 <br /> Facility Name LATHROP SANDS TRAILER COURT <br /> Location 11550 S HARLAN RD <br /> LATHROP, CA 95330 <br /> Phone 209-982-3515 <br /> Mailing Address <br /> P _ <br /> Care of R J STINSON <br /> Location Code 07- LATHROP Alt Phone <br /> BOS District 003 - MOW, VICTOR Fax <br /> APN 19602013 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name JERRY <br /> Title MGR <br /> Day Phone 209-982-3515 <br /> Night Phone 209-982-9492 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000158 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner I Facility 1 Account <br /> Account Name LATHROP SANDS TRAILER COURT (Circle One) <br /> Account Balance as of 61612008: $986.00 <br /> (Circle One) <br /> Transferto Activellnactve <br /> ProgramfElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4242-WASTE WATER TX PLANT PR0420075 EE0007379-AMANDA BOERTIEN Active Y N A I D <br /> 4622-25-99 SERVICE CONNECTIONS(CWS) WA0460818 EE0005838-ADRIENNE ELLSAESSEActive 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,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 he performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws, <br /> APPLICANTS SIGNATURE: Date 61 6 / 0r <br /> Program Records to be TRANSFERED: "$20.00= Amount Paid Date I I <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date / 1 <br /> Payment Type Check Number Received by _ <br /> REHS: Date I / Account out: Date C. 1 <br /> COMMENTS: <br /> Ilphs-ehsgl-ntlappslenvisionslreports15021.rpt <br />