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Date run 4/5/2004 4:49:21 PM SAN JOA N COUNTY ENVIRONMENTAL HEAL' )EPARTMENT Report#5021 <br /> Run by � Pagel <br /> Facility Information as of 4/5/2004 <br /> Record Selection Criteria: Facility ID FA0002805 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0002106 New Owner ID <br /> Owner Name PEARCE, JEFF H <br /> Owner DBA KAISER ROAD TRUST _ <br /> Owner Address 708 GLENHILL CT /lv� .rL �ct(AN V ,&t1�y <br /> NOVATO, CA 94947 <br /> Home Phone 415-898-8052 <br /> Work/Business Phone 415-492-4380 WOO -'3o3-" X>�eo <br /> Mailing Address 708 GLENHILL CT �68'0 �G( (�N U��w �2 <br /> NOVATO, CA 94947 <br /> Care of PEARCE, JEFF H <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0002805 <br /> Facility Name PEARCE, JEFF H 39-40 <br /> Location 5125 S KAISER RD <br /> STOCKTON, CA 95215 <br /> Phone 415-898-8052 <br /> Mailing Address 708 GLENHILL CT - <br /> NOVATO, CA 94947 <br /> Care of PEARCE, JEFF H <br /> Location Code 99- UNINCORPORATED AREA APN:18104006 <br /> BOS District 002 - MARENCO, DARIO SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002366 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner ! Facility / Account <br /> Account Name PEARCE, JEFF H (Circle One) <br /> Account Balance as of 4/5/2004: $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 /> 2755-EMPLOYEE HOUSING PR0270040 EE0003474-CHANDRA OM Active Y N A I D <br /> 4630-NTNC WATER SYSTEM WA0461354 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,PHS/EHD 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 be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date C, f / <br /> Program Records to be TRANSFE ED: $20.00= Amount Paid Date <br /> Water System to be TRANSFERED: $155.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date Account out: Date <br /> COMMENTS: <br /> \\Phs-ehsql-nt\apps\Envisions\Reports\5021.rpt <br />