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AUn byAl*TDYs 4 ' i, �i <br /> Joaquin County PHS HLA' <br /> - - - - - - - - - - - - - - - - - - - - <br /> - - - - - - - - - - - - - - - - - - -FACILITY-'INFORMATION as of " I3 Report #5021 <br /> - - - - - - - - - - - --- - - - - - - - - - - - - - - -/- - - - - - - - - - - ,- - - - - - - - - - - - - - - 1 <br /> OWNER FILE INFORMATION Make changes/corrections in RED pen or pencil; <br /> INFORMATION CHANGt� (date): <br /> OWNERSHIP CHANGE (date): <br /> OWNER ID: 005033 <br /> owner Name: HELLER FIRST CAPITAL CORP New Owner ID: 00 <br /> Owner DBA: HFCC <br /> owner Address: 343 SANSOME ST, STE 900 <br /> SAN FRANCISCO, CA 94104 <br /> Home Phone: 415-274-5700 <br /> work/Business Phone: <br /> Mailing Address: 343 SANSOME ST, STE 900 <br /> Care of: HELLER FIRST CAPITAL CORP <br /> SAN FRANCISCO, CA 94104 <br /> FACILITY FILE INFORMATION <br /> FACILITY ID: 006319 <br /> Facility Name; HFCC <br /> Location: 503 W LARCH RD <br /> TRACY 95376 <br /> Phone: <br /> Mailing Address: 343 SANSOME ST, STE 900 <br /> Care of: HELLER FIRST CAPITAL CORP <br /> SAN FRANCISCO, CA 94104 <br /> Location Code: 03 APN: 212-200-07 <br /> BOS District: 004 sic Code: <br /> 4 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> lti K Ii N� AC'pD�� !S (Jb�'• <br /> ACCOUNT ID: 0007586 ,r �r } New Account ID: 000 <br /> Mail Invoices to: Account � � ��^' nVe Mail Invoices to: Owner /' Facility Account r <br /> Account Name: VE RSAR � 0 (Circleone) <br /> Account Balance as of 03/13/96 : $397.80 I Y- OXIt'S va• (Circle one) <br /> Record UST(s) Transfer to Activate / inactivate <br /> P/E Description ID Employee status Linked new owner? Delete <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - <br /> 2950 ENVIRON ASSESS PR504770 0451 SASSON INACTIVE Y N A' i D <br /> - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - = -11- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, 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 Oa rty.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 /> 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: Date UNIT/File: / / — <br />