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4 <br /> pale run 6114/2010 12:43:28PI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Repan#S <br /> t}zt <br /> Run by <br /> Facility Information as of 6t1 4/2010 Pagel <br /> Record Selection Criteria: Fachily Ip FA0000159 <br /> Make changeslcoTrections in RED ink. <br /> F-1 INFORMATION CHANGE(date) 2 d l 0 <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION j <br /> SSN/Fed Tax ID ; <br /> Owner ID OW0000135 New Owner ID <br /> Owner Name STINSON, ROBERT <br /> Owner DBA <br /> Owner Address p0 BOX q.906 wr 65-5- <br /> Ki M> 461\ P96%SBO. WA 989:70 <br /> Hom6 Phone 36 t? r�g7_4�0 <br /> Work/Business Phone j�Q�6- X60 167-d_1 q3y <br /> I <br /> r Mailing Address PO BOX-$go&14 s i <br /> PeUL-060, WA 960? - - <br /> y Care of STINSON, ROBERT D <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 IMS„-Dve— <br /> Phone 209-gg2 b �IS51-` 4l,3 <br /> Mailing Address 704 I ST STE E <br /> MODESTO, CA 95354 <br /> Care at WOLFE, CATHY <br /> Location Code 07_LATHROP Alt Phone <br /> BOS District 003- BESTOLARIDES Fax <br /> APN 19602013 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name 4RW JDA t�e— j� ReMfIf L- /A iA p <br /> Title MGR <br /> Day Phone 209_882-3rZ 7,0(.[ �`✓�-- �{��✓� <br /> Night Phone 209..982.94-9.2 Ix <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000158 New Account ID <br /> Mail Invoices to pergity FA%C.tLITY A A( M , U)d 1-F Mail 1 Account <br /> Invoices to: Owner 1 f=acility ; <br /> Account Name LATHROP SANDS (cirtl lily <br /> Account Balance as of 6/1412010: $500.00 W�0 Cif L e_ y4 A <br /> (Cirde One) <br /> ProgmmlElerrxrrrt and Description Record 10 Employee ID and Name Transfer to Active/Inac hre <br /> Status New 0~i Delete <br /> 4242-WASTE WATER TX PLANT PRO420075 EE0004045-TED TASIOPOULOS Active Y N A I D <br /> 4622-25-99 SERVICE CONNECTIONS(CWS) WAD460818 EE0005838-ADRIENNE ELLSAESSEInactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT; I,the undersigned owner,operaWr ar agent of same,adcnnwtedge that all site,arwor project specific.PHS/EHD hourly charges associated with This <br /> faality ar equity will be b{{Ipd 10 the party Idenitriad as the OyM 11 Ron this form. !atso certify that all eperatima will be performed in e�ancewith tkl applicable Ordinate Codes and for Standards and <br /> State and/or Federal Lairs. <br /> APPLICP MAW STINSON gate 1 / <br /> Program Y.O. BOX 1635 ount Paid Date—/—/— <br /> Water S) KINGSTON, WA 98346 unt Paid Date 1 � <br /> Payment �W)V--4 S <br /> Received by <br /> REHS: <br /> COMMENT `� Amount out: Date —7 <br /> � fl,�•YJ•�L,�,• <br /> J U L 15 2010 <br /> EiRlRMgMEiff iriEALTH <br /> !'E�RMi-1JSEIRVICES <br />