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Date run 612/2009 4:41:40PN SAN JOIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> Run,by Pagel <br /> Facility Information as of 6/12/20 <br /> Record Selection Criteria: Facility ID FA0000720 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0000576 New Owner ID <br /> Owner Name MADSEN, ROBERT&CAROL <br /> Owner DBA MADSEN'S SUNRISE DAIRY <br /> Owner Address 239 S STOCKTON <br /> RIPON, CA 95366 x,17 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-599-3405 <br /> Mailing Address PO BOX 1386 Z'3� <br /> Care of <br /> RIPON, CA 953661386 rFG � JOAJUIN r <br /> EFMEA6EN gf,,c,, — <br /> FACILITY FILE INFORMATION ` <br /> Facility ID FA0000720 <br /> Facility Name MADSEN'S SUNRISE DAIRY <br /> Location 239 S STOCKTON ST <br /> RIPON, CA 95366 <br /> Phone 209-599-3715 <br /> Mailing Address PO BOX 1386 <br /> RIPON, CA 953661386 <br /> Care of rFFax <br /> Location Code 05-RIPON BOS District 005-ORNELLAS, LEROYfi <br /> APN 25927805 GJ EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION a <br /> Contact Name MADSEN, ROBERT �y. <br /> Title 21 V-l�v°�`r 14 <br /> Day Phone Q oSc D <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000719 New Account ID: <br /> Mail Invoices to Facility 4 -C � Mail Invoices to: Owner / Facility / Account <br /> Account Name MADSEN'S SUNRISE DAIRY �6� �� (Circle One) <br /> Account Balance as of 6/12/2009: $175.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owren Delete <br /> 1615-RETAIL MKT<2000 SO FT (PREPKGD/LTCPRO161550 EE0001084-STEPHANIE RAMIREZ Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO521557 EE0002670-MUNIAPPA NAIDU Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO511874 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PR0519748 EE0000000-HAZ MAT SJC IDES Active Y N A I D <br /> 2301 -UST STATE SURCHARGE FEE PRO508308 EE0007289-ALISON YOUNGBLOODInactive Y N A I D <br /> 2361 -UST FACILITY PR0231482 EE0002670-MUNIAPPA NAIDU Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPR0507261 EE0007289-ALISON YOUNGBLOOD 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 spec,PHS/EHD hourly charges associated with this <br /> 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 Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date_/ / Account out: Date / / <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />