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Date run 4/27/2010 1:19:17PK SAN JO,6^'IIN COUNTY ENVIRONMENTAL HEAL"' DEPARTMENT Report#5021 <br /> Run by' 4006 Pagel <br /> Facility Information as of 4/27/20'1., <br /> Record Selection Criteria: Facility ID FA0016065 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATIO*Spef <br /> SSN/F Tax ID �� 0 0 0 1 D-7 <br /> Owner ID New Owner ID : 0 W 001,/0b 3 _ <br /> Owner NameS QA 1LW007b LT V o'tu� C—S EG L. <br /> Owner DBA _ <br /> Owner Address _ D p�6CLLz r� tt�� <br /> Home Phone Cas�) 3 Ss IJ I)S' <br /> Work/Business Phone Not Sp ifie <br /> Mailing Address <br /> IRTIE <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0016065 <br /> Facility Name g PR@PER-�S-. Cob 5{gyp <br /> Location ,z7IVgg�n/n1,T,�_� 11.99 Ic LL_A LAG-0 (��y <br /> MANTECA, CA -95367- gS337 <br /> Phone <br /> Mailing Address <br /> D 0 p e VCGcut.Ti'/tc <br /> Care of K -5A-y3 )ZA tita,J, Q. 4? 4 <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 005 - ORNELLAS, LEROY Fax <br /> APN 24+0304$ 2,q 1 Sao(3 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name KEN FRITZ <br /> Title PROPERTY MGR <br /> Day Phone 209-957-0331 <br /> Night Phone 209-649-9326 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0028034 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name BECK PROPERTIES (Circle One) <br /> Account Balance as of 4/27/2010: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2965-WATER QUALITY SITE PROJECT PR0523856 EE0000997-HARLIN KNOLL Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,th ersi Lemowner;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 party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: �T���tl�`7 AAJrP, Date <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: *$372.00= Amount Paid W31S Date <br /> Payment Type ✓ Check Number BS3 2- Received b <br /> REHS: I+K Date / / Account out: Date _/�/� <br /> COMMENTS: <br /> RECEIVED <br /> APR 29 2010 <br /> ykN JOAQUIN OOd1W( <br /> lFNTAL <br /> HEALTH DE?A RTMENT <br /> \\e h-e n v\e n vi s i o n\re ports\50 2 1.rpt <br />