Laserfiche WebLink
Date run 10/11/2005 9:30:49A SAN JO/ IN COUNTY ENVIRONMENTAL 14EAL�DEPARTMENT <br /> Run by Report tl5021 <br /> Facility Information as of 10/11/2005 Pagel <br /> Record Selection Criteria: Facility ID FA0015830 <br /> Make changeslcorrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> Owner ID OW0001538 New Owner ID : <br /> Owner Name PATEL, DAYARAM <br /> Owner DBA SIERRA MOTEL <br /> Owner Address 3416 E FARMINGTON RD <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone 209_941-9000 <br /> Mailing Address 3416 E FARMINGTON RD <br /> STOCKTON, CA 95205 <br /> Care of PATEL, DAYARAM <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0015830 <br /> Facility Name SIERRA MOTEL <br /> Location 3416 E FARMINGTON RD <br /> STOCKTON, CA 95205 <br /> Phone 209-941-9000 <br /> Mailing Address 3416 E FARMINGTON RD <br /> STOCKTON, CA 95205 <br /> Care of PATEL, DAYARAM <br /> Location Code 99 - UNINCORPORATED AREA APN:17306038 <br /> BOS District 004 -SEIGLOCK, JACK SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0027518 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name SIERRA MOT (Circle One) <br /> Account Balance as of 1011112005: $ 0✓ <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Slatus New Owner? Delete <br /> 3030-UIC PROGRAM SITE PR0523422 EE0000684-MICHAEL INFURNA A ve Y N A 1 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSlEHD 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 /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 I <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date 1 1 <br /> Water System to be TRANSF RED: *$372.00= Amount Paid Date ! / <br /> Payment Type Check Number Recei <br /> RENS: Date (0 / d /—I' Account out: Date 1 1 <br /> COMMENTS: <br /> 11phs-ehsgl-ntlappslenvis ionslreports15021.rpt <br />