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Date run 12130/2014 3.55:51F SAN JC UIN COUNTY ENVIRONMENTAL HEA i DEPARTMENT Report#5021 <br /> Run by 4y ,.WF <br /> Facility Information as of 12/30/2014 Peet <br /> Record Selection Criteria: Facility ID FA0017359 <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 5SN/Fed Tax Ila <br /> Owner ID OW0014200 New Owner ID <br /> Owner Name RICHARD UDOVICH <br /> Owner DBA RICHARD UDOVICH <br /> Owner Address 17602 LAWRENCE RD <br /> ESCALON, CA 95320 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Marling Address 17602 LAWRENCE RD <br /> ESCALON, CA 95320 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA001 7359 10186325 <br /> Facility Name RICHARD UDOVICH <br /> Location 17602 LAWRENCE RD <br /> ESCALON, CA 95320 <br /> Phone 209_838-2196 x0 <br /> Mailing Address 17602 LAWRENCE RD <br /> ESCALON, CA 95320 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 22903026 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 AR0030241 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name RICHARD UDOViCH (Circle One) <br /> Account Balance as of 1213012014: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> ProgramlElemenl and Description Record to Employee ID and Name Status New Owner? 11,elete <br /> 1958-HM-Farm Operations PR0525544 EE0002474-MICHAEL PARISSI Active Y N A W ❑ <br /> 2840-AST EXEMPT FRC < 1,320 GAL PR0531080 EE0000753-WILLY NG InactivE Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532802 InaCtIVE Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. 1,the undersigned owner,operator or agent of'same,acknowledge that all site,and+or project specific,PHSIEHD hourly charges associated with thisfacility <br /> or activity will be billed to the party identified as the OWNER on this form 1 a1sc certify that all operations will be performed in accordance with all applicable Ordinance Codes andlor Standards and State andler <br /> Federal Laws, <br /> APPLICANT'S SIGNATURE: Date I I <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date 1 I <br /> Water System to be TRANSFERED: Amount Paid Date 1 I <br /> Payment Type Check Number Receiv d y <br /> RENS: Date i O 1 1 Account out: Date <br /> COMMENTS: <br /> S P X E 'TV M-(L, to 9 o J I t N Hf S"f (411-)o 'T14 A-7 N E t� <br />