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Date run 1/12/2021 12:06:29PI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Rur.by <br /> Facility Information as of 1/12/2021 Pagel <br /> Record Selection Criteria: Facility ID FA0004101 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 3 SSN/Fed Tax ID <br /> Owner ID OW0000392 New Owner ID <br /> Owner Name SAN JOAQUIN HOUSING AUTHORITY <br /> Owner DBA <br /> Owner Address 448 S CENTER <br /> STOCKTON, CA 95202 <br /> Work/Business Phone Not Specified <br /> Alternative Phone Not Specified <br /> Mailing Address 2575 GRAND CANAL BLVD STE 220 \// <br /> STOCKTON, CA 95207 <br /> Care of S J CO HOUSING AUTHORITY <br /> FACILITY FILE INFORMATION APN 00115029 <br /> Facility ID/CERS ID FA0004101 <br /> Facility Name MOKELUMNE MANOR <br /> Location 8960 WALNUT GROVE RD <br /> THORNTON, CA 95686 <br /> Phone <br /> Mailing Address PO BOX S 7W <br /> STO ON, CA 95201 <br /> Care of S J CO HOUSING AUTHORITY ZI <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name HOUSING AUTHORITY <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003763 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name MOKELUMNE MANOR (Circle One) <br /> Email invoice to(up to 2 emails) gjones@hacsj.org; hlane@hacsj.org <br /> Email permit to(up to 2 emails) gjones@hacsj.org; hlane@hacsj.org <br /> Account Balance as of 1/12/2021: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4242-WASTE WATER TX PLANT PR0420078 EE0009488-JEFFREY WONG 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 facility <br /> 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 Ordinance Codes ancl/or Standards and State andror <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 by �� I <br /> EHD Staff: Date / / Account out: 21 Date <br /> COMMENTS: <br /> Invoice#: <br />