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Date am 11/21/2014 10:34:02/ SAP JIN COUNTY ENVIRONMENTAL I DEPARTMENT Report#5021 <br /> Run by %Wmw Pagel <br /> Facility Information as of 11/21/2014 <br /> Record Selection Criteria: Facility ID FA0022462 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID : <br /> Owner ID OW0019892 New Owner ID <br /> Owner Name Dustin Wagner <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-652-5192 <br /> Mailing Address 22176 Skiff Rd. <br /> Escalon, Ca 95320 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022462 10422622 <br /> Facility Name Lazy G Ranch <br /> Location 5624 E Highway 4 <br /> Farmington, CA 95230 <br /> Phone 209-838-7547 x <br /> Mailing Address 22176 Skiff Rd. <br /> Escalon, Ca 95320 <br /> Care of Dustin Wagner <br /> Location Code Alt Phone <br /> BOB District Fax <br /> APN 001009025 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 AR0041106 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name Lazy G Ranch (Circle One) <br /> Account Balance as of 11/21/2014: $0.00 l� <br /> (Circle One) <br /> T Transfer to Actweflnactve <br /> Program4FIemenl and Description 1 1� � Record ID Employee ID and Name Status New Owner? Delete <br /> i <br /> 1921 -HMBP-Regular-Primary Location PR0539277 EE0009817-ROBERT LOPEZ Active Y N AI D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator oragent of same acknowledge that all site,andor Project specific,PHSIEHD hourly charges associated with cility, <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 andor Standards and State andor <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 D to <br /> Payment Type Check Number Recei e ( <br /> REHS: Date�,�/ Z-k / t��' _ Account out: Date <br /> COMMENTS: <br />