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Dana= 12118/2008, 1:51:30P SAN JOAN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/18/20 <br /> Record Selection Criteria: Facility ID FA0013716 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0001275 New Owner ID : <br /> Owner Name 6fgl-FF}},q{y@ `-- G �YL of r �l (Z- <br /> Owner <br /> Owner DBA <br /> Owner Address D <br /> STOCKTON, CA 95219 <br /> Home Phone Not Specified <br /> Work/Business Phone .2g9..964-4&3$-- '0 If- <br /> Mailing Address 15135 W EIGHT MILE RD <br /> STOCKTON, CA 95219 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013716 <br /> Facility Name <br /> Location 15135 EIGHT MILE RD <br /> STOCKTON, CA 95219 <br /> Phone 209,&+-156@'s' s 1 63 <br /> Mailing Address 15135 EIGHT MILE RD <br /> STOCKTON, CA 95219 <br /> Care of AtjBREtlgF-SftnlTF1' Ll-,u.0 L 5 <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District Fax <br /> APN 06908021 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name -gfaltT}i-- ��(C 3pµdac CK <br /> Title <br /> Day Phone-1209--951-6506- 5- 3 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0022962 /I New Account ID: <br /> Mail Invoices to ennei Mail Invoices to: Owner / Facility / Account <br /> Account Name @REVV QQ (Circle one) <br /> Account Balance as of 12/18/2008: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inacive <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2960-RWQCB SITE PR0518132 EEO17p0 42::' RRf@QQA�,,ft,���89��Active Y N A. I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or ant df same,acknawledggee-thaattaallll site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the parry identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinaw Codes and/or Standards and <br /> Slate andtor Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid If S '(Z Date �2-/ /D <br /> Water System to be TRAN/SFERED: '$372.00= Amount Paid Date <br /> Payment Type —V Check Number 2 9 ly 3 Received by <br /> . <br /> REHS: Date-LX—I-L Account out: _ `, Date <br /> COMMENTS: <br /> 18'30 DO <br /> \\phs-ehsq I-nt\apps\envisions\reports\5021.rpt <br />