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Date run 3/17/2015 11:58:18AI SAN JOA N COUNTY ENVIRONMENTAL HEAL'�EPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/17/2015 <br /> Record Selection Criteria: Facility ID FA0016929 <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 OW0013770 New Owner ID <br /> Owner Name MEEUWSE RANCH <br /> Owner DBA MEEUWSE RANCH <br /> Owner Address 345 ROSE CT <br /> RIPON, CA 95366 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 345 ROSE CT <br /> RIPON, CA 95366 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0016929 10185635 <br /> Facility Name MEEUWSE RANCH <br /> Location 25150 S MOHLER RD 1.2-0'1 5 D !Gt <br /> RIPON, CA 95366 <br /> Phone 209-599-3298 x0 <br /> Mailing Address 345 ROSE CT <br /> RIPON, CA 95366 I20t{ S Anpk/u <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 25727021 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 AR0029811 NewAccount ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name MEEUWSE RANCH (Circle One) <br /> Account Balance as of 3/17/2015: $0.00 <br /> (Circle One) <br /> Transfer to ACtive/InaCNe <br /> Progmm/Element and Description Record ID Employee ID and Name Status New Owner Delete <br /> 1958-HM-Fane Operations PRO525114 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2840-AST EXEMPT FAC < 1,320 GAL PR0531034 EE0000753-WILLY NG Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO534263 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,me undersigned owner,operator or agent of same,acknowledge that all site,andor project specHio.PHS/EHD hourly charges associated with this RoJay <br /> or activity will be billetl to the party Identified as the OWNER on this form I also cenlfy that all operations will be pedocned 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 is Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Receive/tl�b <br /> REHS: Date_/ / Account out: /A� Date <br /> COMMENTS: <br />