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Date run 1/1512015 9'.59:51AN SAN JO 'J IN COUNTY ENVIRONMENTAL HEA' 1 DEPARTMENT Report#5021 <br /> Run by <br /> Pagel <br /> Facility Information as of 111512015 <br /> Record Selection Criteria: Facility ID FA0016835 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 SSN 1 Fed Tax ID <br /> Owner ID OW0013676 New Owner ID <br /> Owner Name FRANCES STAPELBERG <br /> Owner DBA FRANCES STAPELBERG 1 GRIZZLY H <br /> Owner Address 20202 N ELLIOTT RD <br /> LOCKEFORD, CA 95237 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 781 <br /> LOCKEFORD, CA 95237 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0016835 10185481 <br /> Facility Name FRANCES STAPELBERG <br /> Location 20202 N ELLIOTT RD <br /> LOCKEFORD, CA 95237 <br /> Phone 209_727-3333 x0 <br /> Mailing Address PO BOX 781 <br /> LOCKEFORD, CA 95237 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 05121052 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 AR0029717 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner I Facility I Account <br /> Account Name FRANCES STAPELBERG (Circle One) <br /> Account Balance as of 1!1512015: $0.00 <br /> {Circle One) <br /> Transfer to Activellnactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PR0525020 EE0008709-JAMIE DE LA ROSA Active Y N A<-7) D <br /> 2840-AST EXEMPT FAC K 1,320 GAL PRO530412 EE0000753-WILLY NG Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532897 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: L,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSJEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER cn this form I also certify that all operations will be performed in accordance with all applicable Ordinance Godes andlor Standards and State andlor <br /> Federal Laws_ <br /> APPLICANT'S SIGNATURE; > Date <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Received b <br /> REHS: Date��1 Account out: Date <br /> COMMENTS: <br />