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Dale fon 7/1/2005 3:02:19PM SAN J�IN COUNTY 9NVIRONMENTAL HE I DEPARTMENT RepcnN5021 <br /> Run by 1273 Pagel <br /> Facility Information as of 7/1/2005 <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 <br /> Owner Address 1001 W CENTER ST <br /> MANTECA, CA 95337 <br /> Home Phone Not Specified <br /> WorkBusiness 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 24130050 <br /> BOS District 005- ORNELLAS, LEROY SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0001084 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name MANTECA, CITY OF (CirdeOne) <br /> Account Balance as of 7/1/2005: $0.00 <br /> e one) <br /> Transfer to Achy ache <br /> Program/Elemefa and Description Recall ID Employee ID end Name Status New Omer? are <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0231593 EE0007289-ALISON YOUNGBLOOD Iqqdha, Y N ��AI D <br /> 2965-WATER QUALITY SITE PROJECT PRO506303 EE0000684-MICHAEL INFURNA Y N %.Z-) I D <br /> 4461 -SLUDGE/ASH SITE PRO440074 EE0003973-ROBERT MCCLELLON nac Ive Y N A I D <br /> BILLING end COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,admowledge that all site,an for protect specific,PHSIEHD 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 accomance with all applicable Ordinaoe 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 beT A S ERED: `$155.00= Amount Paid Date_/ / <br /> Payment Type Check Number Received by <br /> REHS: Date / / O Account out: Date_ 7 <br /> COMMENTS: <br /> \bhs-ehsgl-ntlappstenvisions\reporls\5021.rpt <br />