Laserfiche WebLink
Date run 9/26/2007 9:01:30AN SAN JO,"IUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by,. 4006 Pagel <br /> Facility Information as of 9/26/21,_ <br /> Record Selection Criteria: Facility ID FA0005939 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0004731 New Owner ID :s OVA <br /> Owner Name ESTATE-of A JG1Et-� r <br /> 6A "� siZA— 0—LAL t,I D 3)0,L' A <br /> Owner DBA 1�CoLL- 11.E oL-ry <br /> Owner Address 530 YALE ST <br /> SAN FRANCISCO, CA 94134 <br /> Home Phone g063g- <br /> Work/Business Phone Not Specified <br /> Mailing Address 530 YALE ST <br /> SAN FRANCISCO, CA 94134 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0005939 <br /> Facility Name J <br /> Location 260 S MAIN ST <br /> MANTECA, CA 95336 <br /> Phone <br /> Mailing Address 530 YALE ST <br /> SAN FRANCISCO, CA 94134 <br /> Care of <br /> Location Code 04- MANTECA APN: 22(D 2.01-4 <br /> BOS District 005- ORNELLAS, LEROY SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0006889 New Account ID: <br /> Mail Invoices to Feeiii{ Mail Invoices to: Owner / FacilityAccount <br /> Account Name MODESTO DP 'D1/. 6 U (Cirde One) <br /> Account Balance as of 9/26/2007: $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 /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0503685 EE0007289-ALISON YOUNGBLOOD Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project spedfic,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: �`"=— ' ` ` "4Z Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date 7 <br /> COMMENTS: <br /> JUC4'-� o s-D — o r Usn c GE\VQ <br /> GOVN1� <br /> e? <br /> 1Abk1-1 O <br /> \\phs-e hsq I-nt\apps\envisions\reports\5021.rpt <br />