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Date run 11/19/2012 3:34:43P SAN Jr QUIN COUNTY ENVIRONMENTAL HE. 'H DEPARTMENT Report#5021 <br /> `, Pagel <br /> Run by Ill Facility Information as of 11/19/2012 <br /> Record Selection enters: Facility ID FA0014696 <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 OW0011707 New Owner ID <br /> Owner Name VICTOR RIVARN /JAIME SALAS <br /> Owner DBA V&J ORNAMENTAL IRON WORKS <br /> Owner Address 1201 N FILBERT ST <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-465-3407 <br /> Mailing Address 1201 N FILBERT ST <br /> STOCKTON, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0014696 <br /> Facility Name V&J ORNAMENTAL IRON WORKS <br /> Location 1201 N FILBERT ST <br /> STOCKTON, CA 95205 <br /> Phone 209-465-3407 x0 <br /> Mailing Address 1201 NFILBERT ST <br /> STOCKTON, CA 95205 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 14127026 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0025003 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name VICTOR RIVARN /JAIME SALAS (Circle One) <br /> Account Balance as of 11/19/2012: $2,292.50 <br /> (Circle One) <br /> Transferto AcliveMactve <br /> PrograrniElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO521622 EE0006044-LOWELL ALLEN Active Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0532512 Active Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS/EHD hourly charges associated with sfacility <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 endor Standards and State arM'or <br /> Federal 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 Type Check Number Received by <br /> RENS: Date / / Account out: 142 Date <br /> COMMENTS: <br />