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Date run 8/16/2004 4:26:05PN SAN JUIN COUNTY ENVIRONMENTAL HEI H DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 81 4 <br /> Record Selection Criteria: Facility ID FA0009410 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0007410 Case Number: H03791 New Owner ID <br /> Owner Name RIPON CITY OF <br /> Owner DBA RIPON CITY OF PUBLIC WORKS WEL <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-599-2108 <br /> Mailing Address 259 N W ILMA AVE <br /> RIPON, CA 95366 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0009410 <br /> Facility Name RIPON PW WELLS <br /> Location 1210 S VERA AVE <br /> RIPON, CA 95366 <br /> Phone 209-599-2151 <br /> Mailing Address 1210 S VERA AVE <br /> RIPON, CA 95366 <br /> Care of <br /> Location Code APN:259-330-04 <br /> BOS District 005-ORNELLAS, LEROY SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016410 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name RIPON CITY OF (Circle One) <br /> Account Balance as of 8/16/2004: $0.00 <br /> (Circle One) <br /> Transfer to ActivellnacNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PRO511698 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0519611 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84) PRO502746 EE0007289-ALISON YOUNGBLOODInactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPR0509410 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 andlor 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-ehsq I-nt\apps\Envisions\Reports\5021.rpt <br />