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Date run /21/2003 4:57:46PN SAN JOA(V COUNTY ENVIRONMENTAL HEALTEPARTMENT Report A5021 <br /> RunEjY i Pagel <br /> Facility Information as of 5/21/200 <br /> Record Selection Criteria. Facility ID FA0012153 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION �/ <br /> Owner ID OW0001165 INew Owner ID <br /> Owner Name CITY OF STOCKTON <br /> Owner DBA <br /> Owner Address 305 N EL DORADO ST STE 200 <br /> STOCKTON, CA 95202 <br /> Home Phone 209-465-4528 <br /> Work/Business Phone 209-946-9222 <br /> Mailing Address 22 E WEBER AVE #350 <br /> STOCKTON, CA 95202 <br /> Care of CITY OF STOCKTON <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012153 <br /> Facility Name SOUTH SHORE PARCEL <br /> Location WEBER AVE <br /> STOCKTON, CA 95202 <br /> Phone <br /> Mailing Address 22 E WEBER AVE #350 <br /> STOCKTON, CA 95202 \ It <br /> Care of <br /> Location Code AGO n APN: <br /> BOS District �� 'V ��,(� O 1` I SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION 3 D �'I �p V <br /> i <br /> Account ID ARO 1 CA;iPq S New Account ID: <br /> Mail Invoices to CcOunt CIA Mail Invoices to: Owner / Facility I Account <br /> Account Name SOUTH SHORE PARCEL0 D (circle One) <br /> Account Balance as of 5/21/2003: $934.50 Cq �) It "L' (Circle one) <br /> Transfer to Aclive/lnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2959-NON NPUSEP HZ SITE PRO515450 EE0009488-JEFFREY WONG 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 parry 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 /> Slate and/or Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: _*$155.00= Amount Paid Date <br /> Payment Type -�T Check Number Received by <br /> -REHS: Date ,S / 31 / a3 Account out: 2,eZi Date 63 <br /> COMMENTS: <br /> \\Phs-ehsql-nt\apps\Envisions\Reports\5021.rpt <br />