Laserfiche WebLink
Date con ;11/5/2009 12:10:52PI SAN J' WIN COUNTY ENVIRONMENTAL HE,' 'H DEPARTMENTRun by Rapod MSo21 <br /> Facility Information as of 11/5/2* Pagel <br /> Record Selecriteria Facility ID FA0009948 <br /> Make changes/corrections In RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> SSN/Fed Tax ID <br /> Owner ID <br /> OW0007948 Case Number: H05977 New Owner ID : <br /> Owner Name 4G+*44R4@&8I A}p /9r} A 6D55 i <br /> Owner DBA <br /> Owner-Address 511 N AIRPORT WAY <br /> MANTECA, CA 95336 <br /> Home Phone Not Specified <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 r�/J D SSi A/n G' Ei9Ai/ <br /> Location 511 N AIRPORT WAY <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 Alt Phone <br /> BOB District 003- BESTOLARIDES Fax <br /> APN 19528009 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name DEEM X1'055) <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016948 I New Account ID <br /> Mail Invoices to 6vme, Mail Invoices to: Owner / Facility / Account <br /> Account Name JGgN 4eee(-- <br /> (CircAe One) <br /> Account Balance as of 11/5/2009: $859.50 <br /> (Circe One) <br /> Program/Element and Description Transfer to ActiveMadve <br /> P Record ID Employee ID and Name Status New OwneO Delete <br /> 2220-SM HW GEN<5 TONSNR PRO514106 EE0005642-MICHELLE HENRY Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO512236 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PRO519980 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR,PR0509948 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATRPR0515679 EE0005642-MICHELLE HENRY Active 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 parry identified as the OWNER on this form. I also certify that all operations will be performed in accondence with all applicable Onlinace Codes and/or Standards and <br /> State and/or Federal Laws, <br /> Af->a Rossi I�At7 S�rwic� ii s aoo9 <br /> APPLICANT'S SIGNATURE: -0� 'j,, /� � Date <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: 19;Z/ Date ! ! s / OC Account out: Date��/ / <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />