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Run by : LAURIEB San Joaquin County PHS/EHD Report #5021 FACILITY INFORMATION as of 01/31/97 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Make changes/corrections in RED pen or pencil: OWNER FILE INFORMATION INFORMATION CHANGE (date): OWNERSHIP CHANGE (date): OWNER ID: 002213 New Owner ID: 00 Owner Name: ZUCKERMAN, ROSCOE �yy( Owner DBA: ROSCOE ZUCKERMAN CAMP #316 owner Address: PO BOX 487 STOCKTON, CA 95201 Home Phone: Soc Sec# / Tax ID#: Ownership Type: 01 CORPORATION Mailing Address: PO BOX 487 care of: ROSCOE ZUCKERMANp� r, STOCKTON, CA 95201 FACILITY FILE INFORMATION FACILITY ID: 002963 Facility Name: ZUCKERMAN, ROSCOE 39-316 Location: MCDONALD IS, 1MI NW/TRNR STOCKTON 95206 Phone: 209-464-8355 Mailing Address: PO BOX 487 care of: ROSCOE ZUCKERMAN — STOCKTON, CA 95201 Location Code: 9 9 APN: BOS District: 003 SIC Code: ACCOUNTS RECEIVABLE FILE INFORMATION ACCOUNT ID: 0002525 New Account ID: 000 Mail Invoices to: Facility Mail Invoices to: Owner / Facility / Account Account Name: ZUCKERMAN, ROSCOE 39-316 (Circle one) Account Balance as of 01/31/97 : $0 . 00 (Circle one) Record UST(s) Transfer to Activate / Inactivate P/E Description ID Employee Status Linked new owner? Delete - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 2755 EMPLOYEE HOUSING PR270316 0626 CASTRO ACTIVE Y N A I D 4630 NTNC WS WA461342 0102 ACTIVE Y N A I D - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 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 or activity will be billed to the party identified as the BILLING PARTY on this form. I also certify that all operations will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Date - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PR Records to be TRANSFERED: x $20.00 = Amount Paid Date Water System to be TRANSFERED: x $150.00 = Amount Paid Date Payment Type Check # Recvd by REHS or COUNTER SUPV ate—/—/ ACCT out: J Date/3 ( / UNIT/File: / /