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atc <br /> Dren 1/4/2013 4:1820PM SAN JO/ 'IN COUNTY ENVIRONMENTAL HEAI- DEPARTMENT Report#5021by <br /> Facility Information as of 1/4/20153" Pagel <br /> Record Selection croons: Facility ID FA0009870 <br /> Make changesfcorrections in RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> SSN/Fed Tax ID <br /> Owner ID <br /> OW0007870 Case Number: H05689 New Owner ID <br /> Owner Name MARGARET J RING <br /> Owner DBA FOREST LAKE GOLF COURSE <br /> Owner Address 2450 E WOODSON RD <br /> ACAMPO, CA 952209646 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-369-7464 <br /> Mailing Address 2450 E WOODSON RD <br /> ACAMPO, CA 952209646 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009870 <br /> Facility Name FOREST LAKE GOLF COURSE <br /> Location 2450 E WOODSON RD <br /> ACAMPO, CA 95220 <br /> Phone 209-369-5451 x0 <br /> Mailing Address 2450 E WOODSON RD <br /> ACAMPO, CA 952209646 <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 00505038 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 AR0016870 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name MARGARET J RING (Circle One) <br /> Account Balance as of 1/4/2013: $749.50 <br /> (Circle One) <br /> Transferto Activellnectve <br /> PrograrNElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0520343 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0514072 EE0004636-GARRETT BACKUS Inactive Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO512158 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0509870 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0534423 Inactive Y N A I D <br /> BILLING or COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS/EHD hourly charges associated with Nis facility <br /> or activity will ba billed to the party identified as the OWNER on this form I also certify Nat all operations will be performed in accordance with ell applicable Ordinance Codes andor Standards and State andor <br /> Federal taws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date I / <br /> Water System to be TRANSFERED: Amount Paid Date / I <br /> Payment Type Check Number Racal y <br /> REHS: Q VA We Date(_l0_/28f� Account out: Date <br /> COMMENTS: <br />