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Deane 21'17/2010 10:5121AI SAN -AQUIN COUNTY ENVIRONMENTAL H_:.TH DEPARTMENT Report#5021 <br /> mn b/ 1273 <br /> 1./ Facility Information as of 2/17/2010 Paget <br /> Record Selection crkenc FacMy ID FA0017469 <br /> Make changes/co ret one in RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0014310 New Owner ID <br /> Owner Name GREG KING <br /> Owner DBA GREG KING <br /> Owner Address 13632 DROGE RD <br /> ESCALON, CA 95320 <br /> Home Phone Not Specked <br /> Work/Business Phone Not Specified <br /> Mailing Address 13632 DROGE RD <br /> ESCALON, CA 95320 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017469 <br /> Facility Name GREG KING <br /> Location 13632 DROGE RD <br /> ESCALON, CA 95320 <br /> Phone 209-838-6046 x01 <br /> Mailing Address 13632 DROGE RD <br /> ESCALON, CA 95320 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District `� `(�j.,'�-- Fax <br /> APN 20733016 L�$ C' EMail <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION 'C° <br /> Contact Name <br /> Title <br /> Day Phone \� i <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0030351 New Account ID: -. <br /> Mail Invoices to Owner Mail Invoices to: Owner ! Facility / Account <br /> Account Name GREG KING (Circle One) <br /> Account Balance as of 2/17/2010: $280.00 <br /> (Gree One) <br /> Transfer to Active/inacive <br /> Program/Ebment and Description Record ID Employee ID and Name Status New Owder9 Delete <br /> 2220-SM HW GEN<5 TONSNR PR0530878 EE0002670-MUNIAPPA NAIDU Active Y N AD <br /> 2223-AGRICULTURAL HAZ MAT STORAGE FACILPRO525654 Active Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0530877 EE0002670-MUNIAPPA NAIDU Active,Exempt Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PRO531714 Active Y N A CV <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,are undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSIEHD hourly charges associated w this <br /> facility or activity will be billed to Ne party identined as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinate Codes aeWlor Standards and <br /> State and(or Federal Laws. <br /> APPLICANTS SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Data <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type — Check Number Recelv <br /> REHS: ""r DateQLAL/ rn Account out: Date <br /> COMMENTS: i <br /> Meh-enNenvision Veloorts15021.rot <br />