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Date run 212812014 10:28:28AI SAN JC.,.,,UIN COUNTY ENVIRONMENTAL BEA,,.] DEPARTMENT <br /> Report#5021 Paget <br /> Run by <br /> Facility Information as of 212812014 <br /> Record Selection Criteria. Facility ID FA0012452 <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 OW0007317 Case Number: H03066 New Owner ID <br /> Owner Name LINDEN CO WATER DIST <br /> Owner DBA LINDEN CO WATER DIST#5 (PRIMA <br /> Owner Address 19380 E HWY 26 & FLOOD <br /> LINDEN, CA 95236 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-887-3216 <br /> Mailing Address PO BOX 595 <br /> LINDEN, CA 95236 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0012452 10,184,265 <br /> Facility Name LINDEN CO WATER DIST#6 <br /> Location 19380 E HWY 26 <br /> LINDEN, CA 95236 <br /> Phone 209-887-3216 <br /> Mailing Address PO BOX 595 <br /> LINDEN, CA 95236 <br /> Care of TERESA TANAKA <br /> Location Code 99 - UNINCORPORATED A Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 10517009 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name TERESA TANAKA <br /> Title <br /> Day Phone 209-887-3216 <br /> Night Phone 209-887-3216 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION. <br /> Account ID AR0020309 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner ! Facility ! Account <br /> Account Name LINDEN CO WATER DIST#6 (Circle One} <br /> Account Balance as of 2/28/2014: $0.00 <br /> (Circle One) <br /> 'transfer to Activednactve <br /> ProgramlElemeni and Description Record ID Employee ID and Name Status New Owner? Delete <br /> s <br /> 1926-HMBP-Unstaffed Network Location PR0516086 EE0008709-JAMIE DE LA ROSA Active Y N A (1,,,,'' D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0516087 EE0009999-SITE UNASSIGNED Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. 1,the undersigned owner,operator or agent of same,acknowledge that all site,aniVor project specific,PHSiEHD hourly charges associated with this facility <br /> 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 Ordinance Codes andlor Standards and State andlor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE Date 1 I <br /> Program Records to be TRANSFERED: *$25 00= Amount Paid Date ! / <br /> Water System to be TRANSFERED: Amount Paid_ Date 1 / <br /> Payment Type Check Number Recei y III <br /> REHS: �'�r;�i� Date 3 ! 6 ! Account out: Date <br /> COMMENTS: U <br /> ` 14e, rio t6h c4 1 �Cyl 0 PQ- jokr) W11 V,CWL Z-Zy -lq <br />