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Date run 3/14/2011 9:35:54Ah SAN JOAf"TIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ReportM21 <br /> Run by 5290 Page1 <br /> Facility Information as of 3/14/2011/ <br /> Record Selection Criteria: Facility ID FA0017328 <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 OW0014169 New Owner ID <br /> Owner Name JOHN VAUGHN <br /> Owner DBA JOHN VAUGHN <br /> Owner Address 24819 ARTHUR RD <br /> ESCALON, CA 95320 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 24819 ARTHUR RD <br /> ESCALON, CA 95320 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017328 <br /> Facility Name JOHN VAUGHN L/ > <br /> Location 24819 ARTHUR RD <br /> ESCALON, CA 95320 <br /> Phone 209-838-2898 x0 <br /> Mailing Address 24819 ARTHUR RD V <br /> ESCALON, CA 95320 <br /> Care of <br /> Location Code 99- UNINCORPORATED)b Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 22502004 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 AR0030210 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name JOHN VAUGHN (Ciraeone) <br /> Account Balance as of 3/14/2011: $0.00 <br /> (Circle One) <br /> Transfer to Aclive/Inacive <br /> Program/Elemem and Description Record ID Employee ID and Name Status New OvmeR Delete <br /> 2223-AGRICULTURAL HAZ MAT STORAGE FACILPRO525513 Inactive Y N A <br /> 2840-AST EXEMPT FAC <1,320 GAL PRO529240 EF0000753-WII I Y Mr Active Exempt Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPRO534622 Inactive Y N A -1 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknovAedge that all site,and/or project specific,PHS/EHD houry charges associated with the <br /> facility or activity will be bitted to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: 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 Recei <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />