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Date run 10126/01 9:30:14AM SANWQUIN COUNTY PUBLIC HEALTH SEES Report #: soza <br /> Run by Facility Information as of 10/26/01 Page #. 1 <br /> Record Selection Criteria: Facility ID FA0013383 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID: OW0010518 New Owner ID <br /> Owner Name: BENNET, TIM <br /> Owner DBA: SAN JOAQUIN VALLEY ASSOCIATES <br /> Owner Address: 2333 SAN RAMON VALLEY BLVD <br /> SAN RAMON, CA 94903 <br /> Home Phone: 925-820-6677 <br /> Work/Business Phone: Not Specified <br /> Mailing Address: 411 YOKUT AVE#107 <br /> STOCKTON, CA 95207 <br /> Care of: CROSSWINDS OF CALIF (SFD DEV) <br /> FACILITY FILE INFORMATION <br /> Facility ID: FA0013383 <br /> Facility Name: BRIDGEPORT TRAILS DEVELOPMENT <br /> Location: 1904 CHARTER WAY <br /> Phone: STOCKTON, CA 95206 <br /> Mailing Address: 411 YOKUT AVE#107 <br /> STOCKTON, CA 95207 <br /> Care of: CROSSWINDS OF CALIF <br /> Location Code: APN: <br /> BOS District: SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0022283 New Account ID: <br /> Mail Invoices to: Account Mail Invoices to: Owner/Facility/Account <br /> Account Name: GLENN SPRINGS HOLDINGS INC (Circle one) <br /> Account Balance as of 10/26/01: $0.00 <br /> (Cimle One) <br /> Transfer to ActivrAnacNe <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner.) Del <br /> 2960-RWQCB CLEAN UP SITE PR0517372 EE0000684-MICHAEL INFURNA Active Y N A I <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 <br /> facility 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 Ordinace Codes and/or Standards and <br /> Stale and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date ! / <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: _*$150.00=— Amount Paid Date <br /> Payment Type Check Number Received by <br /> RENS: Date / / Account out: [27 Date 0 /A2 /�_ <br /> COMMENTS: <br /> \\Phs-ehsql-nt\apps\Envisions\Reports\5021.rpt <br />