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4 1 1 -1 �� -el 4/L-'--? <br /> Run by CARL Sa. Ovaquin County PHS/EHD / <br /> Report 45021 FACILITY INFORMATION as of 05/16/95 <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> Make changes/corrections in RED pen or pencil: <br /> OWNER FILE INFORMATION Date of INFORMATION CHANGE: <br /> Date of OWNERSHIP CHANGE: <br /> OWNER ID: 000373 New Owner ID: 00 <br /> Owner Name: ATr7rrTrrr-r nnnnr+E K y,!i-! v IQ L e v <br /> Owner DBA: , 5 Ck, ko P. <br /> Owner Address: �� 3 (0 3 1 VJ hlvr�� 2c� prof b <br /> LODI, CA 95240 <br /> Home Phone: <br /> Work/Business Phone: 209-368 ` 9G V" _ <br /> Mailing Address: Jy <br /> Care of: , K 2 �ic <br /> — <br /> LODI, CA 95240 <br /> FACILITY FILE INFORMATION <br /> FACILITY ID: 000454 / <br /> Facility Name: -f�iii, �� 20 1/14 y1/l�rsln <br /> Location: 13631 N HURD RD <br /> LODI 95240 <br /> Phone: - 09� 3 G O 1 �Un J p <br /> Mailing Address: IS 90 -�T�`��c 1 36 3 (/y 1AV11 �li� �✓1i 1 <br /> �6 <br /> Care of: t�� , rn.nnn K r r'C �e) r <br /> LODI , CA 95240 <br /> Location Code: 9 9 APN: <br /> BOS District: 004 SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ACCOUNT ID: 0000453 New Account ID: 000 _ <br /> Mail Invoices to: Facility Mail Invoices to Owner / Facility <br /> Account Name: YAMUCHI, GEORGE 39- 120 <br /> Account Balance as of 05/16/95 $ 0 . 00 <br /> Record UST(s) Transfer to Activate / Inactivate <br /> P/E Description ID Employee Status Linked new owner? Delete <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> 2755 EMPLOYEE HOUSING PR270120 0740 ASKANAS ACTIVE V N A I D <br /> PUBLIC WATER SYSTEM <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this form. 1 also certify that all operations will be performed in accordance with all applicable SAN JOAQUIN <br /> COUNTY Ordinance Codes an /or St ndardand Stat nd/or ederal Laws. <br /> APPLICANT'S SIGNATURE: ��a M 17 , Date /�/9 <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - _ <br /> Programs to be TRANSFERED: x = Amount Paid .% Date C-;—/ /"6Z/9 <br /> Payment Type C e �, ,�_ Check # 10 -2q Recvd by /S4/ <br /> REHS or COUNTER SUPV: �9/q Date j /_Z4_/95 ACCT out: Date—/—/9— UNIT/FiLe:—/—/9— <br />