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Run by : Si",NDY San Joaquin County PHS/EHD Report #5021 FACILITY INFORMATION as of 01/12/96 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Make changes/corrections in RED pen or pencil: OWNER FILE INFORMATION INFORMATION CHANGE (date): OWNERSHIP CHANGE (date): OWNER ID: 002233 New Owner ID: 00 owner Name: CCRC FARMS C C R C- n(ZtY`S 1-}-C Owner DBA: CCRC FARMS CC[�(-''tdRMS LLC owner Address: 18500 BACON ISLAND RD STOCKTON, CA 95206 Ts;�C� Home Phone: Work/Business Phone: 209-464-2959 Mailing Address: 18500 BACON ISLAND RD care of: CCRC FARMS CCRC, PsRty STOCKTON, CA 95206 FACILITY FILE INFORMATION FACILITY ID: 002992 Facility Name: CCRC Location: MANDEVILLE ISLAND STOCKTON 95206 Phone: 209-464-2959 Mailing Address: PO BOX 248 Care of: CCRC FARMS Cj(j G HOLT, CA 95234 Location Code: 9 9 APN: BOS District: 003 SIC Code: ACCOUNTS RECEIVABLE FILE INFORMATION ACCOUNT ID: 0002554 New Account ID: 000 Mail Invoices to: Facility Mail Invoices to: Owner / Facility / Account Account Name: CCRC FARMS 39-100 (Circle one) Account Balance as of 01/12/96 : $0 . 00 (Circle one) Record UST(s) Transfer to Activate / Inactivate P/E Description ID Employee Status Linked new owner? Delete - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 2755 EMPLOYEE HOUSING PR270100 0626 CASTRO 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 ------------------------------------------------------------------------------- -------------------------------------------------------I—,,----------------------- REHS or COUNTER SUPV: Date /�/ 00 ACCT out: Date / / UNIT/File: / /