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Datehm 2/19/2014 10:41:43AI SAN J0!%-/JIN COUNTY ENVIRONMENTAL HEAtll" 'DEPARTMENT Reportx5021 <br /> Ron by Papel <br /> Facility Information as of 2/19/2014 <br /> Record Selection Criteria: Facility ID FA0003410 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0002534 Case Number: 016193 New Owner ID <br /> Owner Name VAN EGMOND,GERARD IRV TRST1997 <br /> Owner DBA VAN EGMOND, G C (GREENDALE) <br /> Owner Address 8220 E LIBERTY RD <br /> GALT, CA 95632 <br /> Home Phone 209-712-7482 <br /> Work/Business Phone Not Specified <br /> Mailing Address 8270 E LIBERTY RD <br /> GALT, CA 95632 _C7 a '?3Z,3 2— <br /> Care of GERARD VAN EGMOND IRV TRST1997 <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERSID FA0003410 10,181,143 <br /> Facility Name VAN EGMOND, G C (GREENDALE) <br /> Location 8220 E LIBERTY RD <br /> GALT, CA 95632 <br /> Phone 209-712-7482 <br /> Mailing Address 8270 E LIBERTY RD PO edy-6-Eo <br /> GALT, CA 95632 �ejt 11,VQ2— <br /> Care of GERARD VAN EGMOND IRV TRST1997 <br /> Location Code 99- UNINCORPORATED P Ah Phone <br /> BOB District 004 -VOGEL, KEN Fax <br /> APN 00703027 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name VAN EGMOND, GERARD C <br /> Title <br /> Day Phone 209-334-9118 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002987 New Account ID: <br /> Mail lnvoicesto Facility Mail Invoices to: Owner / Facility I Account <br /> Account Name VAN EGMOND, G C (GREENDALE) (Circle One) <br /> Account Balance as of 2/19/2014: $266.00 <br /> (Circle One) <br /> Transferto Activellnac e <br /> Progran iElemem and Description Record ID Employee ID and Name Status New Owns/! Delete <br /> 1958-HM-Farm Operations PRO525946 Active Y N A 1 D <br /> 2011 -GRADE A DAIRY PR0200140 EE0004689-KADEANNE LINHARES Inactive Y N A I D <br /> 2220-SM HW GEN<5 TONSNR PRO530459 EE0001422-ARIS CACAPIT Active Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PR0530458 EE0001422-ARIS CACAPIT Active,l Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0531862- Inactive Y N A I D <br /> 4620-DAIRY- WATER SUPPLY WA0515671 EE0004589-KADEANNE LINHARES Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,ac4,nowledge Net all site,anNor project specific,PHSrEHD hourly charges associated with this faolity <br /> or activity will be billed to the party identified!as Me OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State ardor <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 Re iv y <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> !�Pe �r1�1/� �� <br />