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RecordSeV-Ctlteda: <br /> Facility ID COUNTY ENVIROArMENTAL <br /> FA0012215 Facility Infor HEA <br /> oration as of 7/ DEPARTMENT <br /> 26�2D Repor p5021 <br /> Pagel <br /> OWNER FILE INFORMATION Make changes/correcti <br /> Owner ID 0 ons <br /> INFORMATION s i RED ink. <br /> 00058 4 N/ OWNERSHIP ANGE(date) <br /> Owner DBA <br /> Owner Name SSFed Tax ID : CHANGE <br /> � (date) — <br /> OwnerAddressMANT WAY NewQvnerJD : W <br /> 1425 S AIRPORT R e C 0 t $0 z <br /> Home Phone A• CA 95336 <br /> Work/Business Phone <br /> Mailing Address gg <br /> RA <br /> Care of C <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012215 Site Mitigation Facility <br /> Facility Name KrqP8RqSr <br /> Location 14253 S AIRPORT WAY <br /> MANTECA, CA 95336 <br /> Phone <br /> Mailing Address gQS--Ry6y-e+ <br /> Care of <br /> Location Code P9- UNINCORPORATED A Alt Phone <br /> DOS District (03 - BESTOLARIDES Fax <br /> APN '9803004 Entail: <br /> EMERGENCY NOTIFICATI011 CONTACT INFORMATION <br /> Contact Name �DuII <br /> Jess �{ fl 5sa . <br /> Title <br /> Day Phone O 6 E X07 <br /> Night Phone I Dd <br /> ACCOUNTS RECEIVABLEFILE INFORMATION <br /> Account ID AR0019685 New Account ID: <br /> Mail Invoices to Mail Invoices to: Owner / Facility / Account <br /> Account Name (Circle One) <br /> Account Balance as of 728/2010: $0.00 <br /> (Circle One) <br /> Record ID Employee ID and Name Transfer to Activelinaclve <br /> Program/Element and Dsscpbon Status New Omer? Delete <br /> PR05155 qA'E� <br /> 2950-ENVIRON ASSESS 7— = fit J�OLI. Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the wtdersigned ownemnator or agent of same,acknowledge hat all site,andlor project specific,PHS/EHD hourly charges associated with this <br /> MI o acrvlty win be bele,to Ne Pant identified as Ne OWNER on this form.sc certify that all operations will be performed in accordance with all applicable Oli inace Codes and/or Standards and <br /> State and/or Federal Laws- <br /> APPLICANT'S SIGNATURE: � r`r TAcVP Date <br /> Program Records to be TRANSFERED: '$20.00 Amount Paid <br /> te <br /> Water System to be TRA FERED: '$372.00= Amount Paid _ Date / <br /> Payment Check Number ,'.b7s Receive y <br /> �l/ <br /> RENS: Date / Account out: _I Date <br /> COMMENTS: L <br /> O�L <br /> \\eh-env\envision\reports\5021.rpt <br />