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` N4 y� <br /> Run by : NORA San Joaquin County PHS/EHD <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ---FACILITYINFORMATION- - <br /> - <br /> aso£ 03/04/96 Report #5021 <br /> OWNER FILE INFORMATION 11 Make changes/corrections in RED - <br /> pen or pencil: <br /> INFORMATION CHANGE (date): <br /> I OWNERSHIP CHANGE (date): <br /> OWNER ID: 005891 <br /> New Owner 00 <br /> Owner Name: KING ISLAND TRLR PARK & REC CO ID: <br /> i <br /> owner DBA: KING ISLAND RESORT & HOLIDAY H <br /> Owner Address: PO BOX -7-6i- f LA 1, 1 � <br /> STOCKTON, CA 95201 „ <br /> Home Phone: 209-465-5883 <br /> Work/Business Phone: 209-951-2169 <br /> Mailing Address: PO BOX 9"0-2- 146 1 <br /> Care of: DAN MCDANIELS <br /> STOCKTON, CA 95201 <br /> FACILITY FILE INFORMATION <br /> 'I <br /> FACILITY ID: 007171 �- <br /> - <br /> Facility Name: HOLIDAY HARBOR/INTREPID MARINE 1� j <br /> Location: 11540 W EIGHT MILE RD f <br /> STOCKTON 95219 p <br /> Phone: 209-951-2169 <br /> if <br /> Mailing Address: PO BOX Z <br /> l ZcJ— l baa <br /> Care of: DAN MCDANIELS o <br /> STOCKTON, CA 95201 <br /> Location Code: 99 pPN: <br /> BOS District: SIC Code: <br /> ,�4 �C> WedACCOUNTS RECEIVABLE FILE INFORMATION � pZ 'l�OJ.p gjs ' <br /> ACCOUNT ID: 001.0431 New Account?ID: 000 vb <br /> Mail Invoices to: Facility Mail Invoices to: Owner / Fa lity: / ACCO <br /> Account Name: HOLIDAY HARBOR/INTREPID MARINE (Circl <br /> Account Balance as of 03/04/96: $288 . 60 <br /> (Circle one) i <br /> Record UST(s) Transfer to Activate / Inactivate <br /> P/E Description ID Employee status Linked new owner? Delete <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - --- - - - - - -- - - - - - - - - - - - - - - - - - - - - - <br /> 2950 ENVIRON ASSESS PR506051 0684 INFURNA ACTIVE Y N A I D <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or f <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. I also certify that alt operations will be performed ineaccordance with all applicable SAN JOAQUIN <br /> COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - -If- <br /> � - - - - - - - - - - - - - - - -� - - - - - - - - - -- - <br /> PR Records to be TRANSFERED• x $20.00 Amount Paid ' Date <br /> Water System to be TRANSFE D: x $150.00 = Amount Paid Date <br /> Payment Type �f Check # u Recvd by <br /> REHS or COUNTER SUPV Date `ACCT out Dater 3 UNIT/File: / / <br /> ;f <br /> U, <br /> *f <br />