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Eselection <br /> :OOPM :FA001S2215 <br /> AN�QUIN COUNTY PUBLIC HEALTH SES Report #: 0002 <br /> Facility Information as Of 5/16/01 Page #: 1 <br /> Facility ID <br /> Record ID <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE (date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID: OW0005834 New Owner ID <br /> Owner Name: DE GROOT, JERRY <br /> Owner DBA: C DE GROOT & SONS <br /> owner Address: 14253 S AIRPORT WAY <br /> MANTECA, CA 95336- <br /> Home Phone; 209-599-7432 <br /> Work/BussnessPhone: 209-471-1787 <br /> Mailing Address; 908 RUBY CT <br /> RIPON, CA 95336- <br /> care of; C DE GROOT&SONS <br /> FACILITY FILE INFORMATION <br /> Facility ID: FA0012215 <br /> Facility Name: C DE GROOT& SONS <br /> Location: 14253 S AIRPORT WAY <br /> MANTECA, CA 95336 <br /> Phone: 209-471-1787 <br /> Mailing Address: 908 RUBY CT <br /> RIPON, CA 95336- <br /> care of; C DE GROOT& SONS <br /> Location Code: 99 - UNINCORPORATED AREA APN; <br /> Bos District: 005- BEDFORD, LYNN Sic code; <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0019685 New Account ID:- <br /> Maillnvoicesto: Facility Mall Invoices to: Owner/Facility/Account <br /> Account Name: C DE GROOT& SONS <br /> Account Balance as of 5/16/01: $0.00 (Circle One) <br /> (Circle One) <br /> UST(s) Transfer to Active/mactve <br /> Program/Element and Description P Record ID Employee ID and Name atusLinked New Owner? Delete <br /> 2950-ENVIRON ASSESS PR0515525 EE0000684-INFURNA A 've Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific, <br /> PNS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on this farm. I also certify that all <br /> operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$0.00= Amount Paid Date <br /> Water System to be T FERE '$150.00= Amount Paid Date <br /> Payment Type Check Number Receipt Number Received by <br /> REHS:91 Date_/ /li / <br /> Account out: Date �P / O/ / / <br /> 1.0.0.89.00 <br />