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Run by : CARL San Joaquin County PHS/EHD Report #5021 FACILITY INFORMATION as of 05/16/95- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - � �� Make changes/corrections in RED pen or pencil: OWNER FILE INFORMATION Date of INFORMATION CHANGE: Date of OWNERSHIP CHANGE: OWNER ID: 000373 New Owner ID: 00 Owner Name: YAMU H-I, rr'n E- 1t�ST KV,s +v ptiev- r,,;, 1, 5 Owner DBA: , S x W p Owner Address: i 3 (, -3 1 N 14 R J b LODI, CA 95240 Home Phone: Work/Business Phone: Mailing Address: .3(� 3 t (V 1 II�L �,� �,�f-.0k Care of: K r s ( D��n l ✓ `mac LODI, CA 95240 till FACILITY FILE INFORMATION FACILITY ID: 000454 Facility Name: "-YAM� �-3�—=2 0 Location: 13631 N HURD RD LODI 95240 Phone: - '9) 3 G 8- Mailing Address: 1590 VISTT nn __ ) 36 31 (V tout- IM -o?� Care of: YAM- zxr—QEv GE- K r� Py LODI, CA 95240 Location Code: 9 9 APN: IJAYMENT BOS District: 004 SIC Code: RECEIVED ACCOUNTS RECEIVABLE FILE INFORMATION MAY 16 1995 SAN JOAQUIN COUNTY ACCOUNT ID: 0000453 New Account ID: 000 P1 Of I HEALTH SERVICES Mail Invoices to: Facility Mail Invoices to OWn ONFAI9�4-I-KTHDIVISION Account Name: YAMUCHI, GEORGE 39-120 Account Balance as of 05/16/95 $ 0 . 00 Record UST(s) Transfer to Activate / Inactivate P/E Description ID Employee Status Linked new owner? Delete - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 2755 EMPLOYEE HOUSING PR270120 0740 ASKANAS ACTIVE V N A I D PUBLIC WATER SYSTEM - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 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 an /or Stndard and Stat nd/or ederal Laws. APPLICANT'S SIGNATURE: ,�,7LIa ,u �/ , C- Date /�/9 Programs to be TRANSFERED: x = Amount Pai B�7 Date �—� / /9 Payment Type C(,�e k— Check # Recvd by _Z:��) -------------------------------------------------------------_------------------ REHS or COUNTER SUPV: Date ,S / /9� ACCT out: Date /( /9 5 UNIT/File: / /9—