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ERecord <br /> 5/14/2003 8:00:15AA SAN JOA' -'TN COUNTY ENVIRONMENTAL HEAL- -DEPARTMENT Report#5021 <br /> Facility Information as of 5/14/200 Page <br /> Selection Criteria: Facility ID FA0013829 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> Owner ID OW0010926 New Owner ID <br /> Owner Name KOOYMAN, MIKE R <br /> Owner DBA KOOYMAN & SON DAIRY <br /> Owner Address 6787 E JAHANT RD <br /> ACAMPO, CA 95220 <br /> Home Phone 209-368-6523 <br /> Work/Business Phone Not Specified <br /> Mailing Address 6787 E JAHANT RD <br /> ACAMPO, CA 95220 <br /> Care of MIKE R KOOYMAN <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013829 <br /> Facility Name KOOYMAN DAIRY/LAB CLEAN UP <br /> Location 6787 E JAHANT RD <br /> ACAMPO, CA 95220 <br /> Phone 209-368-6523 <br /> Mailing Address 6787 E JAHANT RD <br /> ACAMPO, CA 95220 <br /> Care of MIKE R KOOYMAN <br /> Location Code 99- UNINCORPORATED AREA APN: <br /> BOS District SIC Cade: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0023276 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner ! Facility I Account <br /> Account Name KOOYMA IRY/LAB CLEAN UP (Circle One) <br /> Account Balance as of 51141200 . $0.00 <br /> Transfer to (Circle <br /> Activ n <br /> Program/Element and Description actve <br /> Record ID Employes ID and Mame Status New Owner? pe <br /> 3030-UI CONTROL PROG SITE PRO518315 EE0000684-MICHAEL INFURNA Active Y N A I y!1) <br /> BILLING and COMPLIANCE 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 /> facility or activity will be billed to the party identified as the OWNER on this form. t also certify that all operations will be performed in accordance with all applicable Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date ! / <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date I ! <br /> Water System to be TRANSFERED: *$155.00= Amount Paid to ! / <br /> Payment Type I Check Numberd by <br /> REHS: Date r ! /�� Account a L Date •1_ 1 <br /> COMMENTS: <br /> 11Phs-ehsql-ntlappslEnvisions\Reports15021.rpt 74 <br />