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Run by :SANDY Shue Joaquin County PHS/EHD -.a Report #5021 FACILITY INFORMATION as of 06/09/99 ------------------------------------------------------------------------------- OWNER 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 DBA: Owner Address: i 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 RL care of: VERN DALE MCPHERSC LODI, CA 95242 Location code: 02 "N:059-020-12 Bos District: 004 SIC Code: ACCOUNTS RECEIVABLE FILE INFORI _______________________________________________________________________________ BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/ERD hourly chargee 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 ------------------------------------------------ _______________________________ PR 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 // / _/ ACCP out: k Date / 4L UNIT/File:_/_/_ ACCOUNT ID: 0017989 / New Account ID: UUU Mail Invoices to: Account ��/ Mail Invoices to: Owner Facility / Account Account Name: MCPHERSON ENTERPRISE FAB & MAI (Circle one) Account Balance as of 06/09/99: $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 510989 0000 SJC OES ACTIVE Y N A I D 2224 HAZ MAT BUSINESS PLAN AUTHORIZ 513277 0000 SJC OES ACTIVE Y N A I D 2220 SM HW GEN <5 TONS/YR 514485 0000 SJC OES ACTIVE Y N A I D _______________________________________________________________________________ BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/ERD hourly chargee 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 ------------------------------------------------ _______________________________ PR 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 // / _/ ACCP out: k Date / 4L UNIT/File:_/_/_