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Report #: 0002 <br /> Date run 5/16/01 1:48:38PM SAN I&QUIN COUNTY PUBLIC HEALTH SER&S Page #: 1 <br /> Run by Facility Information as of 5/16/01 <br /> Record Selection Criteria: Facility ID FA0012216 <br /> Record ID <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 DSA: C DE GROOT & SONS <br /> Owner Address: 14253 S AIRPORT WAY <br /> MANTECA, CA 95336- <br /> Home Phone: 209-599-7432 <br /> Work/Bussness 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 <br /> Facility ID: FA0012216 <br /> Facility Name: C DE GROOT & SONS <br /> Location: 13737 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 /> APN; <br /> Location Code: 04 - MANTECA SIC Code: <br /> Bos District: 005- BEDFORD, LYNN <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> New Account ID:: <br /> Account ID: AR0019686 Mail Invoices to: Owner/Facility/Account <br /> Mail Invoices to: Facility (Circle One) <br /> Account Name: C DE GROOT & SONS <br /> Account Balance as of 5/16/01: $0.00 (Circle One) <br /> UST(s) Transfer to Active/Inactve <br /> Record ID Employee ID and Name S ttus Linked New Owner? De e <br /> Program/Element and Description Y N A � v <br /> 2950-ENVIRON ASSESS PR0515526 EE0000684 INFURNA Acttue <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific, <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on this form. I also certify that all <br /> operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and State and/or Federal Laws. <br /> Date I <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: *$0.00= Amount Paid <br /> 150.00= Amount Paid Date <br /> Water System to be TRANS ERED: *$ Received by <br /> Payment Type Check Number Receipt Number <br /> REHS: <br /> Date /�/� Account out: Date <br /> 1.0.0.89.00 <br />