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Datenm is 3/1+4/2013 11:11:05AI SAN JOIN COUNTY ENVIRONMENTAL HEAT•DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/14/2013 <br /> Record Selection Criteria: FacilityID FA0006962 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0005722 New a OwnerName <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified _ 14 A <br /> Mailing Address 551 GORNEG E RT IV <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0006962 <br /> Facility Name r' al PjT_F= G0 PINlorr'.SGI INn nn oe <br /> Location 555 CARNEGIE ST <br /> MANTECA, CA 95336 <br /> Phone—209-824--6523-- <br /> Mailing Address RjQ$eX-t52. <br /> asAN'r GA-9&337 <br /> Care of J4AfdE15J<-CC i <br /> Location Code 04- MANTECA Alt Phone <br /> BOS District 005 -ORNELLAS, LEROY Fax <br /> APN EMail <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name jAMES-1 , <br /> Title <br /> Day Phone <br /> Night Phone 24yg §2.& <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0009917 New Account ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name S (Circle One) <br /> Account Balance as of 3/14/2013: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Progran✓Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PR0505723 EE0000942-MARGARET LAGORIO Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andbr project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. l also certity,that all operations will be performed in accordance with all applicable Ordinance Codes al Standards and State andfor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / / <br /> Water System to be TRANSFERED: Amount Paid Date / / <br /> Payment Type Check Number Recall �yed <br /> REHS: Date / / Account out: ` Date_,7) 43 <br /> COMMENTS: <br />