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Date ren %/19/2013 2:50:48Ph SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5011 <br /> Run,by Paget <br /> Facility Information as of 7/19/2013 <br /> Record Selection Criteria: Facility ID FA0002794 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax 10 <br /> Owner ID OW0002099 New Owner ID <br /> Owner Name SHADOW LAKE MOBILE HM PRK LLC <br /> Owner DBA <br /> Owner Address 4241AABERNATHY RD1I <br /> FAIRFIELD, CA 94534-9717 <br /> Home Phone 510-524-6875 <br /> Work/Business Phone 707-864-0269 <br /> Mailing Address 4341A ABERNATHY RD <br /> FAIRFIELD, CA 94534-9717 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0002794 <br /> Facility Name SHADOW LAKE MOBILE HOME PARK LLC <br /> Location 5100 N HWY 99 <br /> STOCKTON, CA 95212 <br /> Phone <br /> Mailing Address 4341A ABERNATHY RD <br /> FAIRFIELD, CA 94534-9717 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 003 - BESTOLARIDES Fax <br /> APN 08704014 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name WESTERN MOBILE HOME MANAG <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0004516 New Account to <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name SHADOW LAKE MOBILE HOME PARK LLC (Circle One) <br /> Account Balance as of 7/19/2013: $0.00 <br /> (Circle One) <br /> Transfer to Actwonactve <br /> Prograny Eament and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 3611 -PUBLIC POOLISPA-PRIMARY PR0360127 EE0001084-STEPHANIE RAMIREZ Active Y N A I D <br /> 3612-PUBLIC POOUSPA-ADDITIONAL PR0360255 EE0001 084-STEPHANIE RAMIREZ Active Y N A I D <br /> 3612-PUBLIC POOUSPA-ADDITIONAL PR0360256 EE0001084-STEPHANIE RAMIREZ Active Y N A I D <br /> 4242-WASTE WATER TX PLANT PR042OOa4 EE0005944-MICHAEL ESCOTTO Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge Net all site,ander project specific,PHS/EHO hourly charges associated with this facility <br /> or activity will be billed to the party identified ea the OWNER on this form I also Partly that all operations will be performed in accordance with all applicable Ordinance Codes ander Standards and State andor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date / / <br /> Payment Type Check Number Received b ,9 <br /> REHS: Date / I Account out: Date <br /> COMMENTS: <br /> �✓Ibu.S �e'.�f2yl..i'�- �pp( n� o��C rtsv Ii�j <br /> cL�cQReSS . �� c�xdleG�S � c�C S 2613 <br />