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Run by SANDY Sari Joaquin County PHS/EHD Report #5021 FACILITY INFORMATION as of 06/07/96 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Make changes/corrections in RED pen or pencil: OWNER FILE INFORMATION INFORMATION CHANGE (date): OWNERSHIP CHANGE (date): OWNER ID: 000373 New Owner ID: 00 Owner Name: MARSH, KRISTOPHER GUY Owner DBA: owner Address: 13631 N HURD RD APT #62_- LODI, CA 95240 Home Phone: 209-368-4615 ^� Soc Sec# / Tax ID#: - p - u ownership Type: 01 CORPORATION / Mailing Address: 13631 N HURD RD APT #6 care of: KRISTOPHER GUY MARSH LODI, CA 95240 FACILITY FILE INFORMATION FACILITY 1D: 000454 �I / r ( L w- C f\� Facility Name: KRISTOPHER–G MAR H 3 '120 v�.�l Location: 13631 N HURD RD LODI 95240 �j. Phone: 90_A 16A 46I-5a4-0Mailing Address: 13631 N HURD RD APT #6 care of: K ISTOPHER GUY MARSH' LODI, CA 95240 PAYWE `_ Location Code: 99 APN: ��A' q�� BOS District: 004 SIC Code: 1`1 1 L), Q 3a ?p/ ;AN,IUAOUIN COUNTY `J ACCOUNTS RECEIVABLE FILE INFORMATIO-*LIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ACCOUNT ID: 0000453 New Account ID: 000 Mail Invoices to: Owner Mail Invoices to: Owner / Facility / Account Account Name: MARSH, KRISTOPHER GUY (Circle one) Account Balance as of 06/07/96 : $0 . 00 (Circle one) Record UST(s) Transfer to Activate / Inactivate P/E Description ID Employee Status Linked new owner? Delete - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 2755 EMPLOYEE HOUSING PR270120 0740 ASKANAS 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 Date—/—/— ACCT out: Date/ /�II/� UNIT/File:—/—/— V NIT/File: / /