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Date run : 12/13/00 3:56:48PM SAN ' QUIN COUNTY PUBLIC HEALTH SEF' -S Report #: 0002 <br /> Run by DWILSON L� Facility Information-Bs of 12/13/00 Page #: 1 <br /> Record Selection Criteria: Facility ID FA0007093 <br /> L <br /> Record ID <br /> Make changes/correctio in RED ink or pencil. <br /> INFORMATION CHANGE (date) <br /> OWNERSHIP CHANGE (date) <br /> OWNER FILE INFORMATION <br /> Owner ID: OW0005826 New Owner ID <br /> Owner Name: QUALEX <br /> Owner DBA: QUALEX <br /> Owner Address: 555 INDUSTRIAL PARK DRIVE <br /> MANTECA, CA 95336- <br /> Home Phone: Not Specified <br /> Work/Bussness Phone: Not Specified <br /> Mailing Address: 555 INDUSTRIAL PARK DRIVE <br /> MANTECA, CA 95336- <br /> care of: QUALEX <br /> FACILITY FILE INFORMATION <br /> Facility I : 093 <br /> Facility Name: QUALEX WAa <br /> Location: 555 INDUSTRIAL PARK DR <br /> MANTECA, CA 95336 <br /> Phone ��//��,,�� <br /> Mailing Address: 555 INDUSTRIAL PARK DRIVE 106L t�V <br /> MANTECA, CA 95336- <br /> Care of: QUALEX <br /> Location Code: 04- MANTECA APN, <br /> BOS District: 005 -CABRAL, ROBERT SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0010260r New Account ID:: <br /> Mail Invoices to: Facility k0D <br /> Mail Invoices to: Owner/ Facility/Account <br /> Account Name: QUAL � (Circle One) <br /> : $Account Balance as of 12/13/04,096.00 (Circle One) <br /> UST(s) Transfer to Active/Inactve <br /> /Element and Description Record ID Employee ID and Name Status Linked New Owner? Delete <br /> 727r-GEN 5<25 TONS PERMIT PRO505938 EE0000418-KITH Active Y N A I D <br /> 2231 -HAZARDOUS WASTE PBR FACILITY PRO507092 EE0000418-KITH Active Y N A D <br /> 2211 -HAZ WASTE PBR FAC STATE SERVICE FEE PRO507093 EE0007289-YOUNGBLOOD Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FI PR0507094 EE0007289-YOUNGBLOOD Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that an site,and/or <br /> 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 <br /> form. 1 also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and State and/or Federal <br /> Laws. <br /> APPLICANTS SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: `$0.00= Amount Paid Date I / <br /> Water System to be TRANSFERED: '$150.00= Amount Paid Date <br /> Payment Type Check Number Receipt Number Received by <br /> RENS: Date / / Account out: Date <br /> 1.0.0.89.00 <br />