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Date run 5/4/2005 11:04:42AM SAN JOA'("1IN COUNTY ENVIRONMENTAL HEAL7"DEPARTMENT Report#5021 <br /> Run by „ Pagel <br /> Facility Information as of 5/4/200a " <br /> Record Selection Criteria: Facility ID FA0012751 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> �(/ OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION /`p <br /> t=.. <br /> Owner ID OW0000781 New Owner ID <br /> Owner Name ST JOSEPHS REGIONAL HOUSING CO <br /> Owner DBA ST JOSEPHS REGIONAL HOUSING CO <br /> Owner Address 3400 WAGNER HTS <br /> STOCKTON, CA 95209 <br /> Home Phone 209-943-2000 <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 213008 <br /> STOCKTON, CA 952139008 <br /> Care of ST JOSEPHS REGINAL HOUSING <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012751 <br /> Facility Name OAK CREEK AT OCONNOR WOODS <br /> Location 3550 WAGNER HEIGHTS RD <br /> STOCKTON, CA 95209 <br /> Phone 209-956-3434 <br /> Mailing Address 3550 WAGNER HEIGHTS RD <br /> STOCKTON, CA 95209 <br /> Care of OAK CREEK AT O'CONNOR WOODS <br /> Location Code 01 -STOCKTON APN: <br /> BOS District SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0021310 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name OAK COCONNOR WOODS (Circle One) <br /> Account Balance as of 5/4/2005: <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PR0516709 EE0003361 -MARIBEL FLOHRSCHUTActive 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 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 <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 Check Number Received by <br /> RENS: Date�_/�_/�Z Account out: I-K Date �/_ l os­ <br /> COMMENTS: <br /> tc <br /> � s c.M �Lc ti VD0Ifq <br /> \\phs-ehsql-nt\apps\envisions\reports\5021.rpt <br />