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Report #: 0002 <br /> Date run : 7/17/00 4:15:50PM SAWAQUIN COUNTY PUBLIC HEALTH SFlCES Page #: 1 <br /> Run by AYOUNGBLOOD Facility Information as of 7/17/00 <br /> Record Selection Criteria: Facility ID FA0010987 <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: OW0008987 Case Number: H09106 New Owner ID <br /> Owner Name: PACIFIC COAST BUILDING PRODIaUT 'ErCOLUC* <br /> Owner DBA: <br /> Owner Address: <br /> Home Phone: Not Specified <br /> Work/Bussness Phone: 916-444-9304 <br /> Mailing Address: PO BOX <br /> 164 _p�cg <br /> SaU,aXIfoCA015910 <br /> Care of: <br /> FACILITY FILE INFORMATION <br /> Facility ID: FA0010987 <br /> Facility Name: ANDERSON TRUSS <br /> Location: 2050 E LOUISE AVE <br /> LATHROP, CA 95330 20 <br /> Phone: 209-858-5584 <br /> Mailing Address: POBOX160488CA q <br /> Care of: PACIFIC COAST BUILDING PRODUCT <br /> APN: <br /> Location Code: SIC Code: <br /> BOS District: 003-SIMAS, EDWARD <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> New Account ID:; <br /> Account ID: AR0017987 <br /> Mail Invoices to: Owner/ Facility/Account <br /> Mail Invoices to: Facility (Circle One) <br /> Account Name: ANDERSON TRUSS <br /> Account Balance as of 7/17/00: $0.00 (Circle One) <br /> UST(s) Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status Linked New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR <br /> PR0514483 EE0007289-YOUNGBLOOD Active Y N A I D <br /> Y N A I D <br /> 2399 UNIFIED PROGRAM FAC STATE SERVICE FI PR0510987 EE0000000-SJC OES Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513275 EE0000000 SJC OES Active <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 BILLING PARTY on this <br /> form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and State and/or Federal <br /> Laws. <br /> Date <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: *$0.00= Amount Paid <br /> Amount Paid Date <br /> Water System to be TRANSFERED: *$150.00= Received by <br /> Payment Type Check Number Receipt Number <br /> REHS: <br /> Date / / Account out: Date <br /> 1.0.0.89.00 <br />