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ARL San Joaquin County PHS/EHD sport #5021 <br /> a - - - - - - -FACILITY INFORMATION as of 09/20/95,I <br /> Make yY ms in RED pen or pencil: <br /> OWNER FILE INFORMATION ice^ '�' �`'� "'OR ite): <br /> OWNER <br /> OWNER ID: 002106 New Owner ID: 00 <br /> Owner Name: <br /> Owner DBA: <br /> owner Address: 5125 S KAISER RD O C% <br /> STOCKTON, CA 95215 <br /> Home Phone: _ <br /> Work/Business Phone: 209-463-1919 11` a <br /> Mailing Address: <br /> Care of: , MARTIN <br /> • T6N, <br /> FACILITY FILE INFORMATION <br /> FACILITY ID: 002805 �� <br /> Facility Name: , <br /> g-} an <br /> Location: 14 <br /> STeC <br /> Phone: ^ "9 ' 919 �� - �/�Z L <br /> Mailing Address: R—RD <br /> Care of: A , <br /> S ' <br /> Location Code: 99 APN: 0 1995 <br /> BOS District: 004 SIC Code: <br /> U I IV C;Ol l r`!1 1' <br /> ACCOUNTS RECEIVABLE FILE INFORMATION LTH SERVICE( <br /> _ HEALTH DIVISION <br /> ACCOUNT ID: 0002366 New Account ID: <br /> Mail Invoices to: Facility Mail Invoices to: Cility / Account <br /> Account Name: , � ) <br /> Account Balance as of 09/20/95 : $39 . 00 ircle one) <br /> Record UST(s) Tr vate / Inactivate <br /> P/E Description ID Employee Status Linked ne Delete <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> 11U <br /> 2755 EMPLOYEE HOUSING 0 0:0D PR270040 9157 BARCELLOS ACTIVE A I D <br /> 4630 NTNC WS 01l=p,00 WA461354 0370 ACTIVE A I D <br /> - - •• - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> - - - - <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same at all site and/or <br /> project specific PHS/EHD 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 accordan icable SAN JOAQUIN <br /> COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: <br /> - <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> - - - - -1/'-11- - - - - - - - - - - - - - - - - - - - -�- - - <br /> PR Records to be TRANSFERED: x $20.00 Amount Pa , <br /> - / -/ <br /> Water System to be TRANSFERED: x $150.00 = Amount aid _ <br /> Payment Type Chec <br /> REHS or COUNTER SUPV Date / / ACCT out: Date File:—/— <br /> / <br />