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Dalerun '0114/2007 3:49:21 PR SAN JOA '1N COUNTY ENVIRONMENTAL HEALT--DEPARTMENT Report#5021 <br /> Ru{by Page1 <br /> Facility Information as of 9/14/200 <br /> Record Selection Criteria: Facility ID FA0002794 <br /> Make changes/corrections In RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0002099 New Owner ID <br /> Owner Name <br /> Owner DBA <br /> Owner Address 820 KAINS AVE#108 <br /> ALBANY, CA 94706 <br /> Home Phone 510-524-6875 <br /> Work/Business Phone 707-864-0269 <br /> Mailing Address 820 KAINS AVE#108 <br /> ALBANY, CA 94706 <br /> Care of BIGG <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0002794 <br /> Facility Name SHADOW LAKE MOBILE HOME PARK LLC <br /> Location 5100 N HWY 99 <br /> STOCKTON, CA 95212 <br /> Phone <br /> Mailing Address 820 KAINS AVE#108 <br /> ALBANY, CA 94706 <br /> Care of <br /> Location Code 99- UNINCORPORATED AREA APN:08704014 <br /> BOS District 003-MOW, VICTOR SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0004516 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility I Account <br /> Account Name SHADOW LAKE MOBILE HOME PARK LLC (Circle One) <br /> Account Balance as of 911412007: $0.00 <br /> (Circle One) <br /> Transfer la <br /> ActiveRnaclve <br /> Program/Element and Description Record tD Employee ID and Name Status New OwneO Delete <br /> 3611 -PUBLIC POOL/SPA-PRIMARY PR0360127 EE0006213-VIDAL PEDRAZA Active Y N A I D <br /> 3612-PUBLIC POOL/SPA-ADDITIONAL PR0360255 EE0006213-VIDAL PEDRAZA Active Y N A I D <br /> 3612-PUBLIC POOL/SPA-ADDITIONAL PR0360256 EE0006213-VIDAL PEDRAZA Active Y N A 1 D <br /> 4242-WASTE WATER TX PLANT PR0420084 EE0005944-MICHAEL ESCOTTO 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,PHSIEHD 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 Ordinate Codes and/or Standards and <br /> Slate and/or Federal Laws. (' <br /> APPLICANT'S SIGNATURE: S e le- ��1 o.e�, $A WN +`r` - Date 31 7 <br /> Program Records to be TRANSFERED: $20.00= Amount Paid Date / 1 <br /> Water System to be TRANSFERED: '$372.00 W Amount Paid Date 1 / <br /> Payment Type Check Number Received by <br /> RENS: Date 1 I Account out: Qs— Date `'1 ! L`-1 I U <br /> COMMENTS: <br /> Ilphs-ehsgl-ntlappslenvisionslreports15021.rpt <br />