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Runr.Cy :'SANDY S�reJoaquin County PHS/EHD � Report #5021 FACILITY INFORMATION as of 07/09/99 ------------------------------------------------------------------------------- U-,4ER FILE INFORMATION Make changes/corrections in RED pen or pencil: INFORMATION CHANGE (date): OWNERSHIP CHANGE (date): OWNER ID: 008989 CASE #: H09109 New Owner ID: 00 owner Name: VERN DALE MCPHERSON Owner DEA: Owner Address: Home Phone: Soc Sec# / Tax ID#: Ownership Type: 02 INDIVIDUAL Mailing Address: 1445 CHELSEA WAY Care of: STOCKTON, CA 95209 14 FACILITY FILE INFORMATION FACILITY ID: 010989 Facility Name: MCPHERSON ENTERPRISE FAB & MAINT Location: 280 E ARMSTRONG RD LODI 95242-9420 Phone: 209-333-8716 Mailing Address: 280 E ARMSTRONG RD care of: VERN DALE MCPHERSON LODI, CA 95242 Location Code: 02 APN: 059-020-12 Eos District: 004 SIC Code: 1799 ACCOUNTS RECEIVABLE FILE INFORMATION BILLING and COMPLIANCE ACRNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on this form. I also certify that all operations will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Date ________________________________________________________________ Records to be TRANSFERED: x $20.00 Amount Paid Date _/ / Water System to be TRANSFERED: x $150.00 Amount Paid Date_ / Payment Type Check # Recvd by -------------------------------------------- ____________ RENS or COUNTER SUPV: Date-/-/- ACCT out: Dat e/�/ _ UNIT/File:_/_/ ACCOUNT ID: 0017989 New Account ID: 000 Mail Invoices to: Account Mail Invoices to: Owner / Facility / Account Account Name: MCPHERSON ENTERPRISE FAB & MAI (Circle one) Account Balance as of 07/09/99: $128.50 (Circle one) Record UST(s) Transfer to Activate / Inactivate P/E ------------------------------------------------------------------------------- Description ID Employee Status Linked new owner? Delete 2399 UNIFIED PROGRAM FAC STATE SERV PR510989 0000 SJC OES ACTIVE Y N A I D 2224 HAS MAT BUSINESS PLAN AUTHORIZ PR513277 0000 SSC ORS ACTIVE Y N A I D 2220 SM HW GEN c5 TONS/YR PR514485 6213 PEDRAZA ACTIVE Y N A I D BILLING and COMPLIANCE ACRNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on this form. I also certify that all operations will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Date ________________________________________________________________ Records to be TRANSFERED: x $20.00 Amount Paid Date _/ / Water System to be TRANSFERED: x $150.00 Amount Paid Date_ / Payment Type Check # Recvd by -------------------------------------------- ____________ RENS or COUNTER SUPV: Date-/-/- ACCT out: Dat e/�/ _ UNIT/File:_/_/