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Date run 12/2212014 10:46:141Report#5021 <br /> SAN .JOA IN COUNTY ENVIRONMENTAL HEAL' DEPARTMENT Pagel <br /> 401 —W <br /> Ron by <br /> Facility Information as of 12/22/2014 <br /> Record Selection Criteria. Facility ID FA0000069 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 2 SSN/Fed Tax ID <br /> Owner ID OW0000058 New Owner ID <br /> Owner Name LAGORIO, KATHY <br /> Owner DBA LAGORIO'S FARMINGTON INN <br /> Owner Address 20300 E COMSTOCK RD <br /> LINDEN, CA 952364441 <br /> Home Phone 209-886-5112 <br /> WorklBusiness Phone 2p9-601-5112 <br /> Mailing Address PO BOX 218 <br /> FARMINGTON, CA 95230 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0000069 10180523 <br /> Facility Name LAGORIOS FARMINGTON INN <br /> Location 25550 E HWY 4 <br /> FARMINGTON, CA 95230 <br /> Phone 209-886-5112 x <br /> Mailing Address PO BOX 218 <br /> FARMINGTON, CA 95230 <br /> Care of Kathy Lagorio <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 18722008 Eli <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name LAGORIO, KATHY <br /> Title <br /> Day Phone 209-886.5112 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000068 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name LAGORIO, KATHY (Circle One) <br /> Account Balance as of 12/2212014: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Fiement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1624-RESTAURANT/BAR 21-50 SEATS PRO161416 EE0008999-LEYNA HUYNH Active Y N A I D <br /> 1920-HMBP-Common Materials PRO520835 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO519064 EE0000000-HAZ MAT SJC OES InactivE Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO533626 InactivE Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owneroperator or agent of same,acknowledge that all site,andlor project specific,PEISIEFID hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER an this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andlor Standards and State andlor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 ! <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / ! <br /> Water System to be TRANSFFRED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date ! 1 Account out: Date 1 1 <br /> COMMENTS: <br />