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Date run 5/14/2003 8:07:16AN SAN JOJV COUNTY ENVIRONMENTAL HEA*DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 5/14/2003 <br /> Record Selection Criteria: Facility ID FA0001086 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0000353 New Owner ID <br /> Owner Name MANTECA, CITY OF <br /> Owner DBA CITY OF MANTECA WQCF <br /> Owner Address 1001 W CENTER ST <br /> MANTECA, CA 95337 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-239-8460 <br /> Mailing Address 1001 W CENTER ST <br /> MANTECA, CA 95337 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0001086 <br /> Facility Name MANTECA PUBLIC WORKS <br /> Location 2450 W YOSEMITE AVE <br /> MANTECA, CA 95336 <br /> Phone 209-239-8460 <br /> Mailing Address 2450 W YOSEMITE AVE <br /> MANTECA, CA 95336 <br /> Care of MANTECA PUBLIC WORKS <br /> Location Code 04- MANTECA APN: <br /> BOS District 005-ORNELLAS, LEROY SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0001084 NewAccount ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner ! Facility / Account <br /> Account Name MANTECA CITYOF (Circle One) <br /> Account Balance as of 5/14/2003: 0.00 <br /> Circ, <br /> Transfer to Activ, Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? De <br /> 2381 -UST FACILITY(BEFORE 1/84) PR0231593 EE0007289-ALISON YOUNGBLOODInactive Y N A I D <br /> 2960-RWQCB CLEAN UP SITE(SLIC) PR0506303 EE0000684-MICHAEL INFURNA Active Y N A I D <br /> 4461 -SLUDGE/ASH SITE P 0440074 EE0009649-RODNEY ESTRADA Active Y N A YX- D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknovedge 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 Pai*Da / / <br /> Water System to be TRANSFERED: _*$155.00= Amount Paid <br /> Payment Type Check Number REHS: Date 3-/ l Oj AccounDate��/ <br /> COMMENTS: <br /> \\Phs-ehsgl-nt\apps\Envisions\Reports\5021.rpt <br />