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Date run 7/26/2004 10:32:10AI SAN QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Pagel <br /> Run by <br /> Facility Information as of 7/267 <br /> Record Selection Criteria: Facility ID FA0013386 <br /> y Make changeslcorrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> vat OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0010521 New Owner ID <br /> Owner Name ALEXANDER, DENNIS <br /> Owner DBA CALIFORNIA CONCENTRATE CO <br /> Owner Address 21900 N DEVRIES <br /> LODI, CA 95242 <br /> Home Phone 209-334-9112 <br /> Work/Business Phone Not Specified <br /> Mailing Address 21900 N DEVRIES <br /> LODI, CA 95242 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013386 <br /> Facility Name CALIFORNIA CONCENTRATE CO <br /> Location 18678 N HWY 99 <br /> ACAMPO, CA 95220 <br /> Phone 209-334-9112 <br /> Mailing Address 18678 N HWY 99 <br /> ACAMPO, CA 95220 <br /> Care of DENNIS ALEXANDER <br /> Location Code APN: <br /> BOS District 004-SEIGLOCK, JACK SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0022296 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name CALIFORNIA CONCENTRATE CO (Circle one) <br /> Account Balance as of 7/26/2004: $-115.10 <br /> (Circle One) <br /> Transfer to Activellnacive <br /> ee ID and Name Status New OmoO Delete <br /> Record ID Employee a /Ele ant and Description p Y <br /> -R CCB CLEANUP SITE(SLIC) PR0517377 EE0002482-SAM SAVIG Active Y N A I D <br /> B11 LIN nd COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project speck,PHS/EHO hourly charges associated with this <br /> (a 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 /> late and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: _*$155.00= Amount Paid Date <br /> Payment Type _Check Number Received by �1V <br /> REHS: Ln. Date 10 /—L—/ Account out: !�, Date <br /> COMMENTS: <br /> \\Phs-ehsql-nt\apps\Envisions\Reports\5021.rpt <br />