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Date run 2/20/2015 8:49:26AN SAN JO AN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 2/20/2015 <br />Record Selection Criteria: Facility ID FA0018648 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID <br />OW0015325 <br />Owner Name <br />STEVE J BRISTOW <br />Owner DBA <br />VALLEY LP GAS <br />Owner Address <br />4695 E HARVEST RD <br />ACAMPO, CA 95220 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-810-4887 <br />Mailing Address <br />PO BOX 2717 <br />LODI, CA 95241 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0018648 10186931 <br />Facility Name VALLEY LP GAS <br />Location <br />eAMPn n n 9 Ge - <br />Phone 209-810-4887 x0 <br />Mailing Address PO BOX 2717 <br />LODI, CA 95241 <br />Care of <br />Location Code 99 - UNINCORPORATED P <br />Bos District 004 - WINN, CHARLES <br />APN 05132012 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0033013 <br />Mail Invoices to Owner <br />Account Name STEVE J BRISTOW <br />Account Balance as of 2/20/2015: $290.00 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN /Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail: <br />Mail Invoices to: <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? to <br />1921 - HMBP-Reqular-Primary Location PR0527517 EE0008709 - JAMIE DE LA ROSA Active Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0531623 Inactive Y N A D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this facility <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 andfor Standards and State andror <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />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 Rd by <br />RENS: '3e `,-Cl O.� CA— Date 2— Account out: <br />COMMENTS: <br />