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Rate nun 4/3/2014 10:16:56AM SAN JOIE <br /> IN COUNTY ENVIRONMENTAL HEA DEPARTMENT Paget DEPARTMENT Report#5021 <br /> Ranby Facility Information as of 4/3/2014 <br /> Record Selection Criteria: Facility ID FAD021140 <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 OW0017415 New Owner ID <br /> Owner Name SMITH & HOOK WINERY <br /> Owner DBA CYCLES GLADIATOR WINERY <br /> Owner Address 3750 E WOODBRIDGE RD <br /> ACAMPO, CA 95220 <br /> Home Phone Not Specified <br /> Work/Business Phone 831-678-2132 <br /> Mailing Address PO BOX 40 <br /> ACAMPO, CA 952200040 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0021140 10,187,765 <br /> Facility Name CYCLES GLADIATOR WINERY <br /> Location 3750 E WOODBRIDGE RD <br /> ACAMPO, CA 95220 <br /> Phone 831-585-8756 x0 <br /> Mailing Address PO BOX 40 <br /> ACAMPO, CA 952200040 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 01322007 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0038125 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name SMI INERY (Circle One) <br /> Account Balance as of 4/3/201 . P• — <br /> (Circle One) <br /> Transfer to Active/Inactee <br /> Program/Element and Description RecoN ID Employee ID and Name Status New Owr Delete <br /> 1921 -HMBP-Regular-Primary Location PR0536808 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0536857 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,anNor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also cartity that all operations will be performed in accordance with all applicable Ordinance Codes andar Standards and Stale anaor <br /> Federal Laws. Ir/�' 1 <br /> APPLICANTS SIGNATURE: Pl c_a GC,,V S"�— Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by / <br /> RENS: Date /_a/ �/4 <br /> Account out: Date / 2r / ` <br /> COMMENTS: <br />