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Date run 12/13/2017 11:17:17/ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 12/13/2017 <br />Record Selection Criteria: Facility ID FA0009440 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID OW0007440 Case Number: H04013 <br />Owner Name GUST, SCOTT D <br />Owner DBA <br />Owner Address 17597 BEELER RD <br />Home Phone <br />Work/Business Phone <br />Mailing Address <br />Care of <br />ESCALON, CA 95320 <br />Not Specified <br />Not Specified <br />17597 BEELER RD <br />ESCALON, CA 95320 <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0009440 10182673 <br />Facility Name SCOTT D GUST <br />Location 18719 S BRENNAN RD <br />ESCALON, CA 95320 <br />Phone <br />Mailing Address 17597 BEELER RD <br />ESCALON, CA 95320 <br />Care of GUST, SCOTT D <br />Location Code 99 - UNINCORPORATED P <br />Bos District 004 - WINN, CHARLES <br />APN 24702033 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />�if,Li•Il l�%�//i I <br />Account ID AR0016440 <br />New Account ID: <br />Mail Invoices to ACCOUntS <br />%�Q� v"' -r voices <br />to: Owner / <br />Facility / <br />Account <br />Account Name SCOTT D GUST 9 �C <br />(Circle One) <br />Account Balance as of 12/13/2017: $0.00 ,D/24s� <br />V <br />(Circle One) <br />Transfer to <br />Active/Inactve <br />Program/Element and Description <br />Record ID Employee ID and Name <br />Status <br />New Owner? <br />pelqte <br />1958 - HM -Farm Operations <br />PR0525912 EE0002670 - MUNIAPPA NAIDU <br />Active <br />Y N <br />AV* <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION <br />PR0511728 EE0000000 - HAZ MAT SJC OES <br />Inactive <br />Y N <br />A -"'DD <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F <br />PR0509440 EE0000000 - HAZ MAT SJC OES <br />Inactive <br />Y N <br />A I D <br />2830 - AST FAC - SPCC EXEMPT <br />PR0529187 EE0000032 - JOHN ALANIZ <br />Inactive <br />Y N <br />A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG <br />PR0533819 <br />Inactive <br />Y N <br />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 facility <br />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 Ordinance Codes and/or Standards and State andlor <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Type Check Number Received by <br />EHD Staff: Date ��/�/� Account out: L11 Date / //7 <br />COMMENTS: <br />r <br />Invoice #: <br />r Y---, -fv,- I(,-- (6� 1�3 g- P�_ /-17/13/-7 <br />