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Date run 11/17/2009 11:29:371 SAN JG 1UIN COUNTY ENVIRONMENTAL HEA' i DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 11/17l2�13 <br /> Record Selection Criteria: Facility ID FA0019340 <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 OW0014589 New Owner lD <br /> Owner Name SANGUINETTI INVESTMENTS LLC <br /> Owner DBA <br /> Owner Address 18180 FORMON CT <br /> LINDEN, CA 95236 <br /> Home Phone 209-607-9229 <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 509 <br /> FARMINGTON, CA 95230 <br /> Care of SANGUINETTI JR, RON J <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0019340 <br /> Facility Name FARMINGTON CIRCLE K <br /> Location 4391 S ESCALON BELLOTA RD <br /> FARMINGTON, CA 95230 <br /> Phone 209-607-9229 <br /> Mailing Address 18638 E COPPEROPOLIS RD <br /> LINDEN, CA 95236 <br /> Care of SANGUINETTI INVESTMENTS LLC <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 18713006 EMail : <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name TON SSANGUINETTI <br /> Title MANAGING MEMBER <br /> Day Phone 209-607-9229 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0034369 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name FARMINGTON CIRCLE K (Circle One) <br /> Account Balance as of 11/17/2009: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inacive <br /> Program/Element and Description Record 10 Employee ID and Name Status New Owner.' Delete <br /> 2351 -UST FACILITY-2481 COMPLIANT PR0528866 EE0009488-JEFFREY WONG Temp Inactive Y N A 1 D <br /> 2832-AST FAC 10K-</=100 K GAL CUMULATIVEPRO530554 EE0009488-JEFFREY WONG Active Y N A I D <br /> BILLING and!COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ands project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the parry identified as the OWNER on this form. I also cerlity,that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State andlor Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: `$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: _*$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />