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Date run 12/24/2009 6:47:47A SAN JOVIN COUNTY ENVIRONMENTAL HEA DEPARTMENT <br /> Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/24/2 <br /> Record Selection Curlers: Facility ID FA0019740 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION +�...,,� SSN/Fed Tax ID <br /> Owner ID OW0016196 1 New Owner ID <br /> Owner Name PHILLIPS, JOHN B <br /> Owner DBA <br /> Owner Address 1133 BRISTOL AVE <br /> STOCKTON, CA 95204 <br /> Home Phone 209-944-0909 <br /> Work/Business Phone Not Specified <br /> Mailing Address 1133 BRISTOL AVE <br /> STOCKTON, CA 95204 <br /> Care of <br /> FACILITY FILE INFORMATION Pur'� In <br /> Facility ID FA0019740 <br /> Facility Name IDEALEASE �1.��s� <br /> Location 1137 S STOCKTON ST O <br /> STOCKTON, CA 95206 <br /> Phone 209-944-0909 IOR # d 3 00 3� <br /> Mailing Address 1133 BRISTOL AVE <br /> STOCKTON, CA 95204 <br /> Care of BULLER, MARK <br /> Location Code 01 -STOCKTON ../I c( <br /> BOIS District 001 -VILLAPUDUA t f1 <br /> APN <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0035106 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name IDEALEASE (CirdeOne) <br /> Account Balance as of 12/24/2009: $0.00 <br /> (Circle One) <br /> Transfer to Active/InacNe <br /> Program/Element and Descnption Record ID Employee ID and Name Status New Owner' Delete <br /> 2960-RWQCB SITE PR0530031 EE0006219-LORI DUNCAN 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 /> reality or activity will be billed to the parry iderdifted as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordin ice Codes and/or Standards and <br /> State andlor Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid, '4S — Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date / / <br /> Payment Type t Check Number Received by l.L , A , <br /> RENS: Date / / Account out: Date <br /> COMMENTS: <br /> e lq� gL3 <br /> \\eh-env\envision\reports\5021.rpt <br />