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} <br /> Date run 2/27/2013 11:17:57AI SAN J�'UIN COUNTY ENVIRONMENTAL HEA' 1 DEPARTMENT Report#5021 <br /> Run by OM1. Pagel <br /> Facility Information as of 2/27/2013 <br /> Record Selection Criteria: Facility ID FA0018751 <br /> Make changestcorrections in RED ink. Z-7113 73 <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN I Fed Tax ID <br /> Owner ID OW0015418 New Owner ID <br /> Owner Name SAUL HERNANDEZ <br /> Owner DBA LA TIERRA LANDSCAPE INC <br /> Owner Address 10651 E ADA AVE <br /> STOCKTON, CA 95215 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-467-3362 <br /> Mailing Address 10651 E ADA AVE <br /> STOCKTON, CA 95215 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0018751 <br /> Facility Name LA TIERRA LANDSCAPE INC <br /> Location 10651 E ADA AVE <br /> STOCKTON, CA 95215 <br /> Phone 209467_3362 x0 <br /> Mailing Address 10651 E ADA AVE <br /> STOCKTON, CA 95215 <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 10315008 Entail: <br /> EMERGENCY-NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION S <br /> Account ID AR0033296 ,P New Account ID: <br /> Mail Invoices to Owner E.JR— Mail Invoices to: Owner I Facility I Account <br /> Account Name SAUL H "NA_{� (Circle <br /> Account Balance as of 2127120 3: 1 ^- <br /> � +.r G � J (Circle One) <br /> IF Transfer to Activegnactve <br /> ProgramlElementand Description Recortu Employee ID and Name Status_ New Owner? Delete <br /> 1920-HMBP-Common Materials PRQ527667-_,EE0009817-ROBERT LOPEZ dive._. Y N A1 D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0531454 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,arl project specific,PHSlEHO hourly charges associated with this facility <br /> or activlty 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 Ordinance Codes andlor Standards and State andler <br /> Federal Laws, <br /> 4 <br /> APPLICANT'S SIGNATURE: Date 1 I <br /> Program Records to be TPANSFERED: *$25.00= Amount Paid Date I I <br /> Water System to be TRANSFERED: Amount Paid Date 1 I <br /> Payment Type Check Number Receiv /� <br /> REHS: sz Date 2- 1 2-7 1 i Account out: Date I ! L <br /> COMMENTS: <br /> -e- C,�, to a J k/- S � C5 <br /> V- n LKS r.1 S -e c= <br /> �v � 21Z-71 ( ,? <br />