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Date ran 2/19/2014 9.27:34Ah SAN JCi LTIN COUNTY ENVIRONMENTAL HEA, }DEPARTMENT Report#5021 <br /> Run by �I/ `I/ Pagel <br /> Facility Information as of 2/19/2014 <br /> Record Selection Criteria: Facility ID FA0017351 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0014192 New Owner ID <br /> Owner Name PAUL ADRIAN <br /> Owner DBA PAUL ADRIAN <br /> Owner Address 19803 DAHLIN RD <br /> ESCALON, CA 95320 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-838-2848 <br /> Mailing Address 19803 DAHLIN RD <br /> ESCALON, CA 95320 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS 10 FA0017351 10,186,311 <br /> Facility Name PAUL ADRIAN <br /> Location 20009 DAHLIN RD <br /> Escalon, CA 95320 <br /> Phone 209-838-2848 x0 <br /> Mailing Address 19803 DAHLIN RD <br /> ESCALON, CA 95320 <br /> Care of Paul Adrian <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 24713016 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0030233C New Account ID: <br /> /p <br /> Mail Invoices to Owner q �, Cf 6 � Mail Invoices to: Owner / Facility / Account <br /> Account Name PAULA J (Circle one) <br /> Account Balance as of 2/19/2014: 53.00 n L//` <br /> Circle One) <br /> TransferOwner Activelinai <br /> late <br /> PrograMElemenl and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PR0525536 Active Y N A D <br /> 2840-AST EXEMPT FAC < 1,320 GAL PRO530746 EE0000753-WILLY NG Active,l Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534709 InactivE Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ani project specific,PH&EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this earn. 1 also certify that all operations will be performed in accordance with all applicable Ordinance Codes anclor Standards and State ardor <br /> Fedeml Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date /_/ <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment T e �� I,Ch�eck Number -Received <br /> REHS: �, ATJ � Date / a/ Account out: y Date .2- /ZA / <br /> COMMENTS: <br /> Ply- n A-& <br />