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Date run 8/16/2004 1:24:13PK SAN JUIN COUNTY ENVIRONMENTAL HE H DEPARTMENT Report 45021 <br /> Run by Pagel <br /> Facility Information as of 8/16/2 4 <br /> Record Selection Criteria: Facility ID FA0011027 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0009027 New Owner ID <br /> Owner Name LOCKEFORD COMMUNITY SERVICES D <br /> Owner DBA LOCKEFORD COMMUNITY SERVICE DI <br /> Owner Address PO BOX Z <br /> LOCKEFORD, CA 95237 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-727-5035 <br /> Mailing Address PO BOX Z <br /> LOCKEFORD, CA 95237 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0011027 <br /> Facility Name LOCKEFORD COMMUNITY SVC DIST <br /> Location 17725 N TULLY RD <br /> LOCKEFORD, CA 95237 <br /> Phone 209-727-5035 <br /> Mailing Address PO BOX Z <br /> LOCKEFORD, CA 95237 <br /> Care of <br /> Location Code 99 - UNINCORPORATED AREA APN:053-030-39 <br /> BOS District 004-SEIGLOCK, JACK SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0018027 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name LOCKEFORD COMMUNITY SVC DIST (Circle One) <br /> Account Balance as of 8/16/2004: $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 /> 2214-CalARP FAC STATE SURCHARGE FEE PRO518971 EE0003580-MICHELLE LE Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0514499 EE0008389-DENNIS CATANYAG Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0513315 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2226-CalARP PROGRAM PR0514888 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0520619 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPRO511027 EE0000000-HAZ MAT SJC OES 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 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: 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 <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\Phs-ehsql-nt\apps\Envisions\Reports\5021.rpt <br />