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-1 MEMM <br /> Run by : STAFF On Joaquin County PHS/EHD • eport ,f5021 <br /> FACILITY INFORMATION as of 04/17/96 <br /> ------------------------------------------------------- --------------- <br /> Make , ons in RED pen or pencil: <br /> OWNER FILE INFORMATIONT 1NFOR� ate): <br /> OWNER e): <br /> OWNER ID: 002106 New Owner ID: 00 <br /> owner Name: PEARCE, JEFF H <br /> Owner DBA: KAISER ROAD TRUST <br /> Owner Address: 708 GLENHILL CT <br /> NOVATO, CA 94947 <br /> Home Phone: 415-898-8052 <br /> Work/Business Phone: 209-463-1919 <br /> Jb {l5 - <br /> Mailing Address: 708 GLENHILL CT <br /> care of: PEARCE, JEFF H <br /> NOVATO, CA 94947 <br /> FACILITY FILE INFORMATION <br /> FACILITY ID: 002805 <br /> Facility Name: PEARCE, JEFF H 39-40 <br /> Location: 5125 S KAISER RD <br /> STOCKTON 95215 <br /> Phone: 415-898-8052 <br /> Mailing Address: 708 GLENHILL CT � y���^yn <br /> Care of: PEARCE, JEFF H <br /> NOVATO, CA 94947 <br /> Location Code: 9 9 APN: _ <br /> BOS District: 004 SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ACCOUNT ID: 0002366 New Account ID: <br /> _,Mail Invoices to: Pft,=±-i-ity oLkwr Mail Invoices to <br /> cility / Account <br /> Account Name: PEARCE, JEFF H 39-40 > <br /> Account Balance as of 04/17/96: $50.70 ircle one) <br /> Record UST(s) Tr a vate / Inactivate <br /> P/E Description 1D Employee Status Linked net Delete <br /> ---------------------------------------------------------- -------------- <br /> 2755 EMPLOYEE HOUSING PR270040 9157 BARCELLOS ACTIVE h 1 D <br /> 4630 NTNC WS WA461354 0370 ACTIVE k I D <br /> ------------------------------------------------------- -------------- <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same at all site and/or <br /> project specific PHS/END hourly charges associated with this facility or activity will be bi y identified as the <br /> BILLING PARTY on this form. I also certify that all operations will be performed in accordarx icable SAN JOAQUIN <br /> COUNTY Ordinance Codes and/or Standa-ds and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: <br /> ------------------------------------------------------- -------------- <br /> PR Records to be TRANSFERED: -_ x $20.00 = Amount Paid -/ / <br /> Water System to be TRANSFERED: x $150.00 = Amount Paid —/ / <br /> Pa nt Type Check # <br /> ------------------------------- ---------------------- ______________ <br /> REHS or COUNTER SUPV: C:- Date / A /� � AC T out: Date /� File: <br />