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vn` 82801 11:20:17AM $gQUIN COUNTY PUBLIC HEALTH SERS Report #: 5023 <br /> Run by <br /> Facility Information as of 8/28/01 Page #: 1 <br /> Record selection Criteria: Facility ID FA0004043 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID: OW0002972 New Owner ID <br /> Owner Name: SRRECK6ES BEVE6QPMENT--^ ING — <br /> Owner DBA: <br /> Owner Address: <br /> S7 0C-/t 77)ry C 57 <br /> Home Phone: 209=823=3121 OCT— (003 <br /> Work/Business Phone: 209-823-3121 <br /> Mailing Address: 18800 SPRECKLES RD <br /> MANTECA, CA 95336 <br /> r r of 16FcY rtfiofit}8-- / C� / /� <br /> FACILITY FILE INFORMATION <br /> Facility ID: .FA0004043 <br /> Facility Name: <br /> Location: 18800 S SPRECKELS RD <br /> MANTECA, CA 95336 <br /> Phone: 209-823-3121 <br /> Mailing Address: 18800 SPRECKLES RD <br /> MANTECA, CA 95336 <br /> Care of:—jgFEY{EEM NO 73 lIV-6 <br /> Location Code: 04- MANTECA APN: <br /> BOS District: 005- BEDFORD, LYNN SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR00036870bJN.i/'L New Account ID: <br /> Mail Invoices tom Mail Invoices to: Wner Facility/Account <br /> Account Name: SPRECKLESDEVELOPMENTGOINC (circle One) <br /> Account Balance as of 8/28/01: $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 /> 2960-RWQCB CLEAN UP SITE PR0009289 EE000 3-DhA4E-NHd96ht- Active Y N A I D <br /> L&q M.T. <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 OF 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 /> Stale and/or Federal Laws, <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid 5"'- Date <br /> Water System to be TRANSFERED: •$150.00= Amount Paid L Date <br /> Payment T p Check Number '32- 2-5 Received by <br /> REHS: <br /> TSDate / Z / G / Account out: Date /Z�/� <br /> COMMEN : •Iv' �/ <br /> N <br /> 11 <br /> 7)%qoFp <br /> 4 <br /> \\Phs-ehsgl-nt\apps\Envisions\Reports\5021.rpt <br />