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Date run 9/22/2004 4:37:16PN SANJ( 2UIN COUNTY ENVIRONMENTAL HEA_ -H DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9/22/2004 <br /> Record Selection Criteria: Facility ID FA0010156 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0007460 New Owner ID <br /> Owner Name EAST BAY MUD <br /> Owner DBA EAST BAY MUNICIPAL UTILITY DIS <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 510-287-1086 <br /> Mailing Address PO BOX 24055 MS 704 <br /> OAKLAND, CA 946231055 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010156 <br /> Facility Name MOKELUMNE RIVER HATCHERY <br /> Location 25800 N MCINTIRE RD <br /> CLEMENTS, CA 95227 <br /> Phone 209-759-3383 <br /> Mailing Address PO BOX 158 <br /> CLEMENTS, CA 95227 <br /> Care of <br /> Location Code 99 - UNINCORPORATED AREA APN:2301001 <br /> BOS District 004 - SEIGLOCK, JACK SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017156 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name MOKELUMNE RIVER HATCHERY (Circle one) <br /> Account Balance as of 9/22/2004: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0514203 EE0003580-MICHELLE LE Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0512444 EE0000000-HAZ MAT SJC IDES Active Y N A I D <br /> 2226-CalARP PROGRAM PR0514731 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0520107 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPR0510156 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <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. I also certify that all operations will be performed in accordance with all applicable Ordinace 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 <br /> Water System to be TRANSFERED: '$155.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\phs-ehsql-nt\apps\envisions\reports\5021.rpt <br />