Laserfiche WebLink
Date run 7/11/2002 1:46:47PK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5024 <br /> Run by Pagel <br /> Facility Information as of 7/11/2002 <br /> Record Selection Criteria: Facility ID FA0013829 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0010926 New Owner ID <br /> Owner Name KOOYMAN, MIKE R 7 <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 /> t <br /> Mailing Address 6787 E JAHANT RD <br /> ACAMPO, CA 95220 I <br /> Care of MIKE R KOOYMAN <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013829 I <br /> Facility Name KOOYMAN DAIRY/ LAB CLEAN UP <br /> Location 6787 E JAHANT RD I <br /> ACAMPO, CA 95220 <br /> Phone 209-368-6523 <br /> Mailing Address 6787 E JAHANT RD <br /> ik ACAMPO, CA 95220 t <br /> Care of MIKE R KOOYMAN "1 <br /> Location Code-98--OUT(;)F-C--GUNT-Y- APN: <br /> BOS District SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION t <br /> Account ID AR0023276 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility 1 Account ) <br /> Account Name KOOYMAN DAIRY/LAB CLEAN UP (Circle one) <br /> s <br /> Account Balance as of 711112002: $596.30 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Descriptio Record ID Employee ID and Name Status New Owner? Delete <br /> i <br /> 2950_--ENWRONASSESS PRO518315 EE0000684-MICHAEL INFURNA Active Y N A I D <br /> BILA WG and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSIEHD hourly charges associated with this <br /> facility or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes ardlor Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I I <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: "$155.00= Amount Paid Date / 1 <br /> E Payment Type / Check Number Re/ceived.by <br /> REHS: Date 1 f I A '?,Account out: 4`1 Date 7 / L <br /> COMMENTS: <br />' I <br /> I <br /> IIPhs-ehsgl-ntlappslEnvisionslReports15021.rpt <br />