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Run by : SANDY Sk,,e Joaquin County PHS/EHD `/ Report #5021 <br /> FACILITY INFORMATION as of 01/14/97 <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> Make changes/corrections in RED pen or pencil: <br /> OWNER FILE INFORMATION INFORMATION CHANGE (date): <br /> OWNERSHIP CHANGE (date): <br /> OWNER ID: 000915 New Owner ID: 00 <br /> Owner Name: ACQUISITION CORP <br /> Owner DBA: I <br /> owner Address: PO BOX 2301 <br /> MANTECA, CA 95336 <br /> Home Phone: 209-239-4444 <br /> Soc Sec# / Tax ID#: <br /> Ownership Type: 01 CORPORATION <br /> Mailing Address: PO BOX 2301 <br /> Care of: S <br /> MANTECA, CA 95336 <br /> FACILITY FILE INFORMATION <br /> FACILITY ID: 0011821 <br /> Facility Name: vi'Qlr�Ed�S <br /> Location: 400 INDUSTRIAL PARK DR <br /> MANTECA 95336 <br /> Phone: 209-239-4444 Nr�eIJ" <br /> Mailing Address: PO BOX 2301 — <br /> Care of: umrG P� <br /> MANTECA, CA 95336 `�' <br /> Location Code: 04 APN: <br /> BOS District: 005 SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ACCOUNT ID: 0001180 New Account ID: 000 <br /> Mail Invoices to: Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name: INDY ELECTRONICS (Circle one) <br /> Account Balance as of 01/14/97: $169 .00 (Circle one) <br /> Record UST(s) Transfer to Activate / Inactivate <br /> P/E Description ID Employee Status Linked new owner? Delete <br /> _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ <br /> 2227 GEN 5<25 TONS PERMIT PR220078 3973 MCCLELLON ACTIVE Y N A I D <br /> _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this form. I also certify that all operations will be performed in accordance with all applicable SAN JOAQUIN <br /> COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> - - - - - - - - - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ <br /> PR Records to be TRANSFERED: x $20.00 = Amount Paid Date_ <br /> Water System to be TRANSFERED: x $150.00 = Amount Paid Date_ <br /> Payment Type Check # Recvd by <br /> RENS or COUNTER SUPV Date_/_/_ ACCT out: AZ&tl Date / / UNIT/File:_/_/_ <br /> J <br />