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Date run <br /> Run by 4/9/2009 2:42:57PM SAN �QUIN COUNTY ENVIRONMENTAL HE H DEPARTMENT Report u5021- <br /> , <br /> Facility Information as of 4/9/2009 Pagel <br /> Record Selection Criteria; Facility la FA0000238 <br /> Make changesicorrections in RED ink. <br /> aC INFORMATION CHANGE(date) �Y <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN 1 Fed Tax ID 0 <br /> Owner ID OW001.746 ` New Owner ID <br /> Owner Name h" �rV1` <br /> Owner DBA COLLIERVILLE COUNTRY STO <br /> 5 <br /> Owner Address . <br /> .;699 00THA Mid e—l"t <br /> Home Phone /6 %Z• / <br /> ZP <br /> Work/Business Phone 2D9,..g� <br /> Mailing Address 3706 E COLLIER RD ' <br /> ACAMPO, CA 95220 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0000238 3 ?009 I <br /> Facility Name COLLIERVILLE COUNTRY STORE .. <br /> Location 3706 E COLLIER RD <br /> SAN JOA4UIN UUUN I <br /> ACAMPO, CA 95220ES <br /> OFFI(;E OF EM <br /> Phone 209-369-6375 <br /> Mailing Address 3706 E COLLIER RD ; <br /> ACAMPO, CA 95220 I <br /> Care of <br /> 1 <br /> Location Code 99- UNINCORPORATED_ P Alt Phone <br /> BOS District 004 -VOGEL, KENT Fax - <br /> APN 00514225 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title }� <br /> Day Phone �Cj <br /> Night Phone T) <br /> ACCOUNTS RECEIVABLE FILE INFORMATION 1 . <br /> Account ID AR0000237 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility /'Account <br /> Account Name COLLIERVILLE COUNTRY STORE (circle one) <br /> Account.Balance as of 41912009: $0.00 <br /> I <br /> (CIrGe One) <br /> nactve <br /> Program/Element and Description Record ID Employee ID and Name Status Transfer Atliverl <br /> New Owner 4 Deleetete <br /> 1 617- ETAIL MARKET>1000 SQ FT W/FOOD FPR0161892 EE0006213-VIDAL PEDRAZA n Active Y" N A I D <br /> -:HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO515810 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PRO521169 EEOOD0000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARIPRO515811 EE0000149-RAYMOND BORGES Inactive Y N A I D <br /> 4616-TNG WATER SYSTEM-CURFFL WA0515488 EE0006213-VIDAL PEDRAZA Active Y N A I D <br /> 6tLLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project 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 accordance with all applicable Ordinate Codes and/or Standards and <br /> State and/or Federal Laws, <br /> APPLICANT I R�C�/!� <br /> S SIGNATURE: Date B /�I�� S� 4A O QT <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid 10 tjD Date � /�_/� lv 9 <br /> Water Syste RANSFER�E '$372.00= Amount Paid Date l 1 y�`G��9bQUiN <br /> Payment Ty C k u bar 3 b Received by_�� ��FpyFry�a(q� <br /> RENS: llww Date I 1 Account out: Date <br /> COMMENTS: <br /> 51cV._c .ilo �iinntr.......+..5cnn■ -..a <br />