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I It <br /> Date ran 8/16/2004 4:25:55PR SAN10'QUIN COUNTY ENVIRONMENTAL HS TH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/16/2uu4 <br /> Record selection Criteria: Facility ID FA0000673 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0000538 New Owner ID <br /> Owner Name RIPON CITY OF <br /> Owner DBA <br /> Owner Address 259 N WILMA <br /> RIPON, CA 95366 <br /> Home Phone 209-599-2108 <br /> Work/Business Phone Not Specified <br /> Mailing Address 259 N WILMA <br /> RIPON, CA 95366 <br /> Care of CITY OF RIPON <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0000673 <br /> Facility Name CITY OF RIPON <br /> Location 1210 S VERA AVE <br /> RIPON, CA 95366 <br /> Phone 209-599-2108 <br /> Mailing Address 259 N WILMA <br /> RIPON, CA 95366 <br /> Care of CITY OF RIPON <br /> Location Code 05 - RIPON APN:25933007 <br /> BOS District 005- ORNELLAS, LEROY SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID 0000672 New AccountlD: <br /> Mail Invoic o Faclll ,R.� Mail Inv toner / Facility ! Account <br /> Acco Name C OF N C,t �°I, � l (Circle one) <br /> Account Balance as of 8/ 2004: 0.00 F ro.hC ��; �(b✓ <br /> C G Q Transfer to (Circle One) <br /> Active/Inaclve <br /> Program/Element and Description Record ID Employee ID and Name talus ` New Owner? Delete <br /> 1 <br /> 'dENVIRON ASSESS PRO505712 EE0007479 R^" R^'"'_ AAIrve Y N A I D <br /> 4423-REFUSE VEHICLES PR0440025 EE0005366-LISA MEDINA Active Y N A I D <br /> 4430-SOLID WASTE CIA SITE PR0515731 EE0001699-JOHNNY YOAKUM Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of some,acknowledge that all site.andlor project specific,PHS/EHO hourly charges associated with this <br /> facility or activity will be billed to the party Identllied as the OWNER on this form. I also cerfdy 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 Re ce vedp by <br /> RENS: Date_/ / Account out: L _ Date_�y/�/ 7 <br /> COMMENTS: <br /> \\Phs-ehsq I-nt\apps\Envisions\Reports\5021.rpt <br />