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Date run 8/6/2014 10:03:09AM SAN JUIN COUNTY ENVIRONMENTAL HEA&DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/612014 <br /> Record Selection Criteria: Facility ID FA0015872 <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 SSNI Fed Tax ID <br /> Owner ID OW0012793 New Owner ID <br /> Owner Name RSD <br /> Owner DBA R S D <br /> Owner Address 2882 TEEPEE DR <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone 949-380-7878 <br /> Mailing Address 2.882 TEEPEE DR <br /> STOCKTON, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0015872 10185037 <br /> Facility Name RSD <br /> Location 2882 TEEPEE DR <br /> STOCKTON, CA 95205 <br /> Phone 209-462-7650 x0 <br /> Mailing Address 2882 TEEPEE DR <br /> STOCKTON, CA 95205 <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 13208001 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 AR0027628 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner 1 Facility ! Account <br /> Account Name RSD (circle one) <br /> Account Balance as of 81612014: $0.00 <br /> (Circle One) <br /> Transferto ActivelIri <br /> Program/Element and Description Record ID Employee ID and Name Status N—n—.r? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO523493 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533548 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSIEHD 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 Ordinance Codes andlor Standards <br /> and State andtar Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I ! <br /> Program Records to be TRANSFERED: *$25.00_ Amount Paid Date I I <br /> Water System to be TRANSFERED: Amount Paid Date I ! <br /> Payment Type Check Number Received by <br /> RENS: Date 1 I Account out: Date 1 ! <br /> COMMENTS: <br />