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Datemn , 7/2/2003 8:46:04AM SANJOA 'IN COUNTY ENVIRONMENTAL HEAL' pEPARTMENT Report#5021 <br /> Run � <br /> by i �/ <br /> rri Facility Information as of 7/2/2003 Pagel <br /> Record Selection Criteria: Facility ID FA0012454 <br /> MVEDMake changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> JUL - 3 2rio3 OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> I>Wieousisunixv V4-,..I�Y <br /> Owner I OW0009659 "4MICIFEMERGEN 1-`k)VI1;BJew Owner I <br /> Owner Name C T TITUS 1 M. ET AL <br /> Owner DBA HENKELS AND MCCOY <br /> Owner Address 21881 PHOENIX LAKE RD <br /> SONORA, CA 95370 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-931-5325 <br /> Mailing Address -Mrw <br /> 0`3 ry.ok ,�tuLE . A cg936 <br /> � <br /> Care of A7T ; }/f rr <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012454 <br /> Facility Name HENKELS & McCOY <br /> Location 17751 S IDEAL PKWY <br /> MANTECA, CA 95336 <br /> Phone 209-823-0454 <br /> Mailing Address rj /a- <br /> Care of <br /> Location Code 99- UNINCORPORATED AREA APN: <br /> BOS District 005- ORNELLAS, LEROY SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0020311 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name HENKELS & McCOY (ClrcleOne) <br /> Account Balance as of 7/2/2003: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inaclve <br /> Program0emerd and Description Record ID Employee ID and Name Status New Porrer1 Delete <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PRO516090 EE0009999-SITE UNASSIGNED Active Y N A 1 D <br /> 2244-PACT TRANSFER RECORD-IDES PR0520908 EEOo00000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPR0516091 EE0009999-SITE UNASSIGNED Inactive 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,PHSJEHD hourly charges associated will,this <br /> facility or activity will be billed to the party identified as the OWNER on gds farm. I also certify that all operations vAl be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> Slate and/or Federal Laws. G�, ,A/T�f <br /> APPLICANTS SIGNATURE: 5199 l—z,Act eLb 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 / / Account out: Date - / 2— /-03 <br /> COMMENTS: <br /> Gtk CP-L Le -e <br /> \\Phs-ehsgl-nt\epps\Envisions\Reports\5021.rpt 00 La <br />