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Date run 11/2/2010 2:02:44PN SAN JOA("'IN COUNTY ENVIRONMENTAL HEALT`I DEPARTMENT Report#5021 <br /> Run by , 5290 Pagel <br /> Facility Information as of 11/2/201 <br /> Record Selection Criteria: Facility ID FA0005939 <br /> Make changes/corrections in RED ink. <br /> ' INFORMATION CHANGE(date) <br /> Lf OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0004731 New Owner ID <br /> Owner Name <br /> Owner DBA RTY <br /> Owner Address 5E-5l� <br /> 34 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 513 , $T <br /> 4 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0005939 Site Mitigation Facility <br /> Facility Name gC=EE=PftCFPMTY <br /> Location 260 S MAIN ST <br /> MANTECA, CA 95336 <br /> Phone <br /> Mailing Address 5304,4---T <br /> SAN-FRAMetSeO, CA 4134 <br /> Care of 10 <br /> Location Code 04- MANTECA Alt Phone <br /> BOS District 005- ORNELLAS, LEROY Fax <br /> APN 22102024 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name E <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0006889 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name ,q (Circle One) <br /> Account Balance as of 11/2/2010: $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 /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0503685 EE0007289-ALISON YOUNGBLOOD]nactive Y N A I D <br /> 2950-ENVIRON ASSESS PR0527424SEAQ Q �� <br /> s� Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of me,lKnowledgehat 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 Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />