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Run by : NORA SAN JOAQUICOUNTY PUBLIC HEALTH SERVICES <br /> Report #5021 FACILITY INFORMATION as of 01/04/95 - - - - <br /> _ _ _ _ _ _ _ _ - - - - - - - - - - - - - - - - - <br /> - - - - - - - - - - - - - - - - - - - - <br /> - - - - Make changes/corrections in RED pen or pencil: <br /> Date of INFORMATION CHANGE: <br /> OWNER FILE INFORMATION Date of OWNERSHIP CHANGE: <br /> OWNER ID: 005570 New Owner ID: 00 <br /> owner Name: COSTAMAGNA, ERNEST <br /> owner DBA: FARM UGT <br /> owner Address: PO BOX 262 <br /> BANTA, CA 95304 <br /> Home Phone: 209-481-2864 <br /> Work/Business Phone: 209-481-2864 <br /> Mailing Address: PO BOX 262 <br /> care of: ERNEST COSTAMAGNA <br /> BANTA, CA 95304 <br /> FACILITY FILE INFORMATION <br /> FACILITY ID: 004052 <br /> Facility Name: FARM UGT <br /> Location: 18775 S TOM PAINE RD <br /> TRACY 95376 <br /> Phone: 209-931-3770 <br /> Mailing Address: PO BOX 262 <br /> care of: ERNEST COSTAMAGNA <br /> BANTA, CA 95304 <br /> Location Code: 03 APN: 213-020-30-8 <br /> BOS District: 03 SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ACCOUNT ID: 0003700 New Account ID: 00 <br /> Mail Invoices to: Owner Mail Invoices to: wner Facility <br /> Account Name: COSTAMAGNA, ERNEST <br /> Account Balance as of 01/04/95 : $ -390 . 00 <br /> FILES LINKED: No WATER SYSTEM FILE Linked <br /> Record UST(s) Transfer to Activate / Inactivate <br /> P/E Description ID Employee Status Linked new owner? Delete <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- <br /> 2951 UGT-CAP PR004367 0684 INFURNA ACTIVE Y N A 1 b <br /> 2332 EXEMPT TANK FACILITY PR503170 0142 SNAVELY INACTIVE 1 Y N A I D <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that ail site and/or <br /> project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this form. I also certify that all operations wiLL be performed in accordance with all applicable SAN JOAQUIN <br /> COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - <br /> Programs to be TRANSFERED: x $20.00 Amount Paid Date <br /> Payment Type Check # Recvd by <br /> - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> REHS or COUNTER SUPV: Date / /9 ACCT out: Date / /9_ UNIT/File: / /9 <br />