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Date run 2/16/2016 2:49:40PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 2/16/2016 Record Selection Criteria: Facility ID FA0005777 OWNER FILE INFORMATION Number of facilities for this owner: 1 Owner ID OW0004591 Owner Name LASSEN CANYON NURSERY Owner DBA LASSEN CANYON NURSERY Owner Address 1300 SALMON CREEK RD O CD REDDING, CA 96003 Home Phone Not Specified Work/Business Phone 530-223-1075 Mailing Address PO BOX 992400 APN REDDING, CA 96099-2400 Care of FACILITY FILE INFORMATION Facility ID / CERS ID FA0005777 10181929 Facility Name LASSEN CANYON NURSERY Location 2955 E Palm Ave Manteca, CA 95337 Phone 530-223-1075 x0 Mailing Address PO BOX 992400 O CD REDDING, CA 96099-2400 Care of Elizabeth Ponce Location Code Q a , Bos District 005 - ELLIOTT, BOB APN 22809005 EMERGENCY NOTIFICATION CONTACT INFORMATION Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN /Fed Tax ID New Owner ID : Alt Phone Fax EMail : Contact Name Title PO 50X O CD Day Phone Q a , 4 p cf � _ �cf Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0006508 New Account ID: Mail Invoices to Account Mail Invoices to: Owner / Facility / Account Account Name LASSEN CANYON NURSERY (Circle One) Account Balance as of 2/16/2016: $180.00 (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1920 - HMBP-Common Materials PR0524131 EE0000010 - PETER LOMBARDI Active Y N A I D 2381 - UST FACILITY (BEFORE 1/84) - obsolete PR0503314 EE0007289 - ALISON YOUNGBLOOD Inactive Y N A I D 2830 - AST FAC - SPCC EXEMPT PR0539999 EE0009001 - ELENA MANZO Active Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0534502 Inactive Y N A I D 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 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 and/or Federal Laws. APPLICANT'S SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number EHD Staff: COMMENTS: Date ' $25.00 = Amount Paid Date Amount Paid Date Date Received by Account out: Date _�/L7//0 Invoice #: