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Dale run 11/5/2009 12:10:52PI SAN <br /> Run by "ftw QUIN COUNTY ENVIRONMENTAL HF_TH DEPARTMENT Reponk5021 <br /> Facility Information as of 11/5/2009 Pagel <br /> Rewrd Selection Catena: Facility ID FA0009948 <br /> Make changes/corrections in RED Ink. <br /> INFORMATION CHANGE(date) - <br /> OWNER FILE INFORMATION OWNERSHIPCHANGE(date) <br /> SSN/Fed Tax ID <br /> Owner ID <br /> OW0007948 Case Number: H05977 New Owner ID <br /> Owner Name dGHN R068I A+n /�� p �n5< <br /> Owner DBA lllxjy, s��7t�/cFi <br /> Owner Address-511 N AIRPORT WAY <br /> MANTECA, CA 95336 Pd�4ara �� <br /> Home Phone Not Specified 2 10 <br /> Work/Business Phone 209-823-3965 <br /> Mailing Address PO BOX 332 <br /> MANTECA, CA 95336 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009948 <br /> Facility Name <br /> Location 51N�IRp9fiTW{4Y - �A 5$ A <br /> MANTECA, CA 95336 <br /> Phone 209-823-3965 <br /> Mailing Address PO BOX 332 <br /> MANTECA, CA 95336 <br /> Care of <br /> Location Code 04- MANTECA <br /> Alt Phone <br /> BOS District 003 - BESTOLARIDES Fax <br /> APN 19528009 Ell <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name Tan <br /> Title - J�f v rl J <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016948 <br /> New AccountlD <br /> Mail Invoices to eyyhe -- Mail Invoices to: Owner / Facility / Account <br /> Account Name jgWN4gg31 <br /> g — <br /> Account Balance as of 11/5/2009: $859.50 Circe One) <br /> Program/Element and Description One)tion Recortl ID Employee 10 and NameTransfer to Active/Inact. <br /> Status New Owner! Delete <br /> 2220-SM HW GEN 15 TONS/YR PR0514106 EE0005642-MICHELLE HENRY Active <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO512236 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PR0519980 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> 23999--UNIFIED PROGRAM FAC STATE SURCHARIPRO509948 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2861 -SY N A I D <br /> T FAC >/=1,320-<10 K GAL CUMULATRPR0515679 EE0005642-MICHELLE HENRY Active Y N A I D <br /> a Ct1Mr <br /> and COMPLIANCE ACKNOWLEDGEMENT I I,the undersigned owner,opereloror agent o same,acknowledge that all site,and/or pro)acl apedfic,PHS/EHD hourly charges associatetl with this <br /> facility oractivity will be billed tome party identified as the OWNER on this form I also certify that all operations will be performed In accordance with ell applicable Ordinate Codes and/or Standard.and <br /> State and/or Federal Laws. <br /> Aq�--4 Ro s s ISA Qs�nv�c� <br /> APPLICANT'S SIGNATURE: _ L]• ' Date / S_ , a 009 <br /> Program Records to be TRANSFERED: •$20.00= ! Amount Paid Date <br /> Water System to be TRANSFERED: •$372.00= Amount Paid Date <br /> Payment Type Check Number Receive <br /> REHS: (��Z/ <br /> COMMENTS' Date -/ S / C�j Account out: Date /0 1 <br />