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Dale-um 2/11/2014 4:02:43PN SAN JO. AN COUNTY ENVIRONMENTAL HEAI 'DEPARTMENT Report#5021 <br /> Run by �i Papel <br /> Facility Information as of 2/11/2014 <br /> Record'Selection Criteria'. Facility ID FA0017351 <br /> Make changes/corrections 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 Not Specified <br /> Mailing Address 19803 DAHLIN RD <br /> ESCALON, CA 95320 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID 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 <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 AR0030233 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name PAUL ADRIAN (Circle One) <br /> Account Balance as of 2/11/2014: $53.00 <br /> (Circle One) <br /> Transfer to Adivellnadve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PRO525536 Active Y N A 1 D <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0530746 EE0000753-WILLY NG Active,l Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO534709 Inactivc Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same.acknowledge that all site,anclor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER an this forml also certify that all operations will be performed in accordance with all applicable Ordinance Codes anal Standards and State andor <br /> Federal Lawis. <br /> APPLICANTS SIGNATURE: T I�.G..S�- /'7G�✓lam 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 /> REHS: Date / / Account out: Date <br /> COMMENTS: A n <br /> ::::rA,V0 ie- <br />