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Boa bvS: NOR A Sar Joaquin County PHS/EHD I Report 85021 <br /> FACILII,eINFORMATION as of 07/07/9-mW <br /> -------------------------------------------------------------------------------- <br /> Nike changes/corrections in REO pen or pencil: <br /> OWNER FILE INFORMATION INFORMATION CHANGE (date): <br /> OWNERSHIP CHANGE (date): <br /> OWNER I0: 002901 Neu Owner ID: 00 <br /> Owner Name: SSOI O.w <br /> Owner DBA: MOUNTAIN VALLEY EXPRE S <br /> Owner Address: 1299 VANDERBILT CR <br /> MANTECA , CA 95366 <br /> Home Phone: 209-823-2168 <br /> Work/Business Phone: 209-823-2168 — <br /> Nailing Address: 1299 VANDERBILT CR <br /> Care of: <br /> MANTECA , CA 95366 <br /> FACILITY FILE INFORMATION <br /> FACILITY 003923 <br /> Facility home: S /� n� ' / n� �✓` O <br /> Location: 1299 VANDERBILT CR <br /> MANTECA 95366 �aN" <br /> Phone: 209-823-2168 _.. <br /> Nailing Address: 1299 VANDERBILT CR v <br /> Care of: MOUNTAIN VALLEY EXPRESS <br /> MANTECA , CA 95366 <br /> Location Code: 04 APR: <br /> SOS District: ' SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ACCOUNT 10: 0003515 Now Account ID: 000 <br /> Nail Invoices to: Facility Nail Invoices to: Owner J Facility / Account <br /> Account Name: MOUNTAIN VALLEY EXPRESS (Circle one) <br /> Account Balance as of 07/07/95 : $0 . 00 (Circle one) <br /> Record UST(s) Transfer to Activate I Inactivate <br /> PIE Description ID Employee Status Linked new owner? Delete <br /> ------------------------ ------------------------------------------------------ <br /> 2381 DST FACILITY (BEFORE 1184) PR231448 3973 NCCLELLDN ACTIVE 4 Y N A I D <br /> ----------------------------------------------- -------------------------------- <br /> BILLING and COMPLIANCE ACNNDVLE06ENENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and(or <br /> project specific PNSIEND hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLI06 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 121.11 Amount Paid Date_____) / <br /> Water System to be TRANSFERED: _ x $161./1 • Amount Paid Date,_/ J <br /> Payment Type Check 1 Recvd by <br /> RENS or COUNTER SUPV —= Date. /��'ACCT out: Date= J= / UNITJFile:�/!/_ <br />