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Swerun �t 2/14/2014 4:32:51PN SAN JO, 'JIN COUNTY ENVIRONMENTAL HEAI 'DEPARTMENT Report#5021 <br /> Run by _ t *✓ 'N� Pagel <br /> Facility Information as of 2/14/2014 <br /> Record Selection Criteria: Facility ID FA0016984 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0013825 New Owner ID <br /> Owner Name MANUEL DUTRA <br /> Owner DBA MANUEL J DUTRA JR. <br /> Owner Address 10806 N LOWER SACRAMENTO RD <br /> STOCKTON, CA 95210 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 10806 N LOWER SACRAMENTO RD <br /> STOCKTON, CA 95210 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0016984 10,185,715 <br /> Facility Name MANUEL DUTRA <br /> Location 10806 N LOWER SACRAMENTO RD <br /> STOCKTON, CA 95210 <br /> Phone 209-477-4567 x0 <br /> Mailing Address 10806 N LOWER SACRAMENTO RD <br /> STOCKTON, CA 95210 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 08405003 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0029866 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name MANUEL DUTRA (Circle One) <br /> Account Balance as of 2/14/2014: $53-Ge— <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PR0525169 Active Y N AD <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0530431 EE0000753-WILLY NG Active,l Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532688 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PIIS/EHO hourly charges associated with this facility or <br /> be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and 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 Received ttv <br /> RENS: Date / 14 _/ I Account out: Date <br /> COMMENT��—rZ—j�—fit f <br /> � � <br /> f'AAI.Tp e���) W one VD x',," r W \\Gre V <br /> U <br /> +� 1* tom ( .l S � _ �2ea-II- ►u © 1 (z <br />