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Date run 11/30/2018 9:03:25A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by I <br />Pagel <br />Facility Information as of 11/30/2018 <br />Record Selection Criteria: Facility ID FA0022119 <br />OWNER FILE INFORMATION Number of facilities for this owner: 4 <br />Owner ID <br />OW0016508 <br />Owner Name <br />Oakwood Lake Water District <br />Owner DBA <br />3757 W WOODWARD AVE <br />Owner Address <br />4399 APLICELLA CT <br />MANTECA, CA 95336 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-543-6250 —1,5� <br />Mailing Address <br />PO BOX 690339 <br />Care of <br />Stockton, CA 95269-0339 <br />Care of <br />99 - UNINCORPORATED P <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0022119 10601116 <br />Facility Name <br />OLWD WELL #3 <br />Location <br />3757 W WOODWARD AVE <br />MANTECA, CA 95337 <br />Phone <br />209-483-5525 x <br />Mailing Address <br />PO BOX 690339 <br />Stockton, CA 95269-0339 <br />Care of <br />Valley Operators <br />Location Code <br />99 - UNINCORPORATED P <br />Bos District <br />005 - ELLIOTT, BOB <br />APN <br />241-54-150-000 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name Charles Moore <br />Title <br />Day Phone 209-483-5525 <br />Night Phone <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN/ Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0040339 <br />Mail Invoices to Account Mail Invoices to: <br />Account Name OLWD WELL #3 <br />Account Balance as of 11/30/2018: $375.00 <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/lnactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />01921 - HMBP-Reqular-Primary Location PR0538275 EE0000009 - NICHOLAS LOEHRER Active Y N A I D <br />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 <br />or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State andlor <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />EHD Staff: <br />COMMENTS: <br />* $25.00 = <br />Date <br />Date <br />Amount Paid Date <br />_ Amount Paid Date <br />Received by <br />Account out: Date / <br />Inv ice #: <br />VJ <br />1 <br />V <br />