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Date mn 6/29/2010 4:30:45PR SAO WylInformation <br /> VIRONMENTAL HEA, DEPARTMENT <br /> Run by Report#5021 <br /> as of 6/29/201 Pagel <br /> Record Selection Criteria: Facility ID FA0004043 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> SSN/Fed Tax ID <br /> Owner ID OW 0002972 New Owner lD <br /> Owner Name KIRK, EDWARD B <br /> Owner DBA <br /> Owner Address Pg-Bg�¢38,)z <br /> STOCKTON, CA 95204 <br /> Home Phone 209-603-8292 <br /> Work/Business Phone Not Specified <br /> Mailing Address 24.BDX-4 7 <br /> STOCKTON, CA 95204 <br /> Care of KIRK, BING <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0004043 <br /> Facility Name SPRECKLES BUSINESS PARK <br /> Location 18800 S SPRECKELS RD <br /> MANTECA, CA 95336 <br /> Phone 209-823-3121 <br /> Mailing Address P6-1916X-4467 S t eg V n rn r <br /> STOCKTON, CA 95204 <br /> Care of EDWARD B KIRK <br /> Location Code 04- MANTECA Alt Phone <br /> BOS District 005-ORNELLAS, LEROY Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name BING KIRK <br /> Title <br /> Day Phone 209-603-8292 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003687 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name AKFDEVELOP/SPRECKLES (Circle One) <br /> Account Balance as of 6/29/2010: $0.00 <br /> (Circle One) <br /> Program/Element and Description Transfer to Activennactve <br /> P Record ID Employee ID and Name Status New Owner? Delete <br /> 2960-RWOCB SITE PR0009289 EE0000684-MICHAEL INFURNA 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 <br /> facility or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations vnll be performed in accordance with all applicable Ordinace Codes and/or standardsand <br /> Stale andror Federal Laws. <br /> APPLICANT'S SIGNATURE: e clt � `v Date <br /> Program Records to be TRANSFERED: •$20.00= Amount Paid 345 - Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number _ 3 2-�� Received by �d- <br /> REHS: Date /_/ Account out: V_�C Date <br /> COMMENTS: <br /> pAyMEN dT <br /> �� ac RECEIVED <br /> JUN 2 9 2010 <br /> SAN JOAOUIN COUNTY <br /> \\eh-env\envision\reports\5021.rpt ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />