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Date run 8/2/2004 9:24:OOAM SAN J ZUIN COUNTY ENVIRONMENTAL HEH DEPARTMENT Report#5021 <br /> � Pagel <br /> Run by Facility Information as of 8/2/2 <br /> Record Selection Criteria: Facility ID FA0012215 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0005834 New Owner ID <br /> Owner Name DE GROOT, JERRY <br /> Owner DBA C DE GROOT&SONS <br /> Owner Address 14253 S AIRPORT WAY <br /> MANTECA, CA 95336 <br /> Home Phone 209-599-7432 <br /> Work/Business Phone 209-471-1787 <br /> Mailing Address 908 RUBY CT <br /> RIPON, CA 95336 <br /> Care of C DE GROOT&SONS <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0012215 <br /> Facility Name C DE GROOT&SONS <br /> Location 14253 S AIRPORT WAY <br /> MANTECA, CA 95336 <br /> Phone 209-471-1787 <br /> Mailing Address 908 RUBY CT <br /> RIPON, CA 95336 <br /> Care of C DE GROOT& SONS <br /> Location Code 99 - UNINCORPORATED AREA APN: <br /> BOS District 005 - ORNELLAS, LEROY SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> AccountlD <br /> AR0019685 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name C DE GROOT &SONS (Circle One) <br /> Account Balance as of 8/2/2004: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> New Owner? Delete <br /> Program/Element and Description Record ID Employee ID and Name Status <br /> 2950-ENVIRON ASSESS PR0515525 EE0000684-MICHAEL INFURNA 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,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 /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\Phs-e hsq I-nt\apps\Envisions\Re ports\5021.rpt <br />