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Date run 5/19/2008 8:33:47AN SAN JOIN COUNTY ENVIRONMENTAL HEAL EPARTMENT Report#5021 <br /> Run by pagcl <br /> Facility Information as of 5/19/200 <br /> Record Selection Criteria: Facility ID FA0018700 - <br /> LZMake changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> rr— OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Tax ID <br /> Owner ID RIO( r ID <br /> Owner Name RIPOIP �p <br /> Owner DBA RI8 S <br /> Owner Address 938 S I <br /> RIPON, /� Q <br /> Home Phone 209-47E <br /> Work/Business Phone 209-599 <br /> Mailing Address PO BOX <br /> RIPON, 2 <br /> Care of OUDEN, (� f G/� <br /> FACILITY FILE INFORMATION Atj\/r Facility <br /> Facility ID FA001870( <br /> Facility Name RIPON FAI <br /> Location 932 FRONT - <br /> RIPON, CA <br /> Phone 209-599-218 <br /> Mailing Address 938 FRONTA(,t RD <br /> RIPON, CA 95366 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 005-ORNELLAS, LEROY Fax <br /> APN 26102011 <br /> EMERGENCY NOTIFICATION CONTACT INFORMAT <br /> Contact Name � N1 <br /> Title 1� <br /> Day Phone 209-599-2188 <br /> Night Phone v' <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0033183 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility I Account <br /> Account Name THE SOURCE GROUP (Circle One) <br /> Account Balance as of 5/19/2008: $-49.00 <br /> (Circle One) <br /> Transfer to Active/Inacive <br /> Pmgr a nd Description Record ID Employee ID and Name Status New Owner! Delete <br /> -E NVI ASSESS PR0527598 EE0001459-VICKI MCCARTNEY Active Y N A I D <br /> BIL XU LIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> fall or activity 'II be billed to the parry,identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State ndlur F seal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: `$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Typ Check Number Received by <br /> REHS: X' �w 4 Datex S /�/�� Account out N cT Date S /1"Z/ '0 <br /> COMMENTS: <br /> \\phs-ehsql-nt\apps\envisions\reports\5021.Ipt <br />