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I <br /> Date run 10/25/2018 11:52:06/ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/25/2018 <br /> Record Selection Criteria: Facility ID FA0009944 <br /> Make changesicorrections 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 OW0007944 Case Number. H05948 New Owner ID <br /> Owner Name JIM NICOLAY <br /> Owner DBA N&S IRRIGATION <br /> OwnerAddress 215 W MAIN ST <br /> RIPON, CA 95366 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-599-3456 <br /> Mailing Address PO BOX 805 <br /> RIPON, CA 95366 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID/CERS ID FA0009944 10183051 <br /> Facility Name N&S IRRIGATION <br /> Location 215 W MAIN ST <br /> RIPON, CA 95366 <br /> Phone 209-599-3456 x <br /> Mailing Address 215 W MAIN ST <br /> RIPON, CA 95366 <br /> Care of SANDRA CARHART <br /> Location Code 05 - RIPON Alt Phone <br /> BOS District 005 - ELLIOTT, BOB Fax <br /> APN 25906072 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016944 Df New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name N&S IRRIGATIO (Circle One) <br /> Account Balance as of 10/25/2018: $ _ `'t�� "Zp C, 5 <br /> (Circle One) <br /> Transfer to Active/Inaclve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0520210 EE0000009-NICHOLAS LOEHRER Active Y N A D <br /> 2220-SM HW GEN<5 TONS/YR PR0514104 EE0009818-LYDIA BAKER Active Y N A le5 D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512232 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PRO504055 EE0007289-ALISON YOUNGBLOOD Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0509944 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0534605 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,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 and/or Standards and State andror <br /> Federal Laws. <br /> APPLICANT'S 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 heck Number Received by <br /> EHD Staff: Date / / Account out: ate / 0 rd o <br /> COMMENTS: Ir1V01Ce#k: <br />