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Date run 7/10/2009 1:05:36PN SAN.IOA4JU1N COUNTY ENVIRONMENTAL HEAN-A DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/10/2009 <br /> Record Selection Criteria: Facility ID FA0016913 <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 OW0013754 New Owner ID <br /> Owner Name 44 P-4&iii <br /> Owner DBA HI <br /> Owner Address 16688 E FRENCH CAMP RD (jy <br /> RIPON, CA 95366 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 16688 E FRENCH CAMP RD <br /> RIPON, CA 95366 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0016913 ELM O, FAAnVrr4-LA /QANe. <br /> Facility Name c(4PLg41,NQ-H <br /> Location 16688 E FRENCH CAMP RD <br /> RIPON, CA 95366 <br /> Phone 209-982-4156 x0 <br /> Mailing Address 16688 E FRENCH CAMP RD <br /> RIPON, CA 95366 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 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 AR0029795 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility ! Account <br /> Account Name +tr-M( I (Circle One) <br /> Account Balance as of 7/10/2009: $0.00 <br /> (Guile One) <br /> Transfer to Actee/lnaclve <br /> Program/Element and Desoiphon Record ID Employee ID and Name Status New tamer! Delete <br /> 2223-AGRICULTURAL HAZ MAT STORAGE FACILPRO525098 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT'. 1,the undersigned owner.operator or agent of same,acknowledge that all site,and/or project specific.PHS/EHD hourly charges associated with des <br /> tacitly or activity will W billed to the pany identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinate Codes andfor Standards and <br /> State and(or 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 Racalv <br /> REHS: Date / 16-1-09' Account out: Date <br /> COMMENTS- <br /> \\eh�nv\envision\reports\5021.rpt <br />