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run 1/31/2013 2:21:58PR SAN JC ' )UIN COUNTY ENVIRONMENTAL HEA' '"'R DEPARTMENT Report#5021 <br /> an by <br /> Facility Information as of 1/31/2013 Pagel <br /> Record Selection Criteria: Facility ID FA0016955 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN I Fed Tax ID <br /> Owner ID OW0013796 New Owner lD <br /> Owner Name SKS ENT <br /> Owner DBA SKS ENT <br /> Owner Address 18832 MELLO AVE <br /> RIPON, CA 95366 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 1300 <br /> LOCKEFORD, CA 952371300 <br /> Care of <br /> FACILITY FILE: INFORMATION <br /> Facility ID FA0016955 <br /> Facility Name SKS ENT <br /> Location 18832 MELLO AVE <br /> RIPON, CA 95366 <br /> Phone 209_983-0642 x0 <br /> Mailing Address PO BOX 1300 <br /> LOCKEFORD, CA 952371300 <br /> Care of <br /> Location Code 99 _ UNINCORPORATED P Alt Phone <br /> BOS District 005 _ORNELLAS, LEROY Fax <br /> APN 24513017 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 AR0029837 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name SKS ENT (Circle One) <br /> Account Balance as of 113112013: $0.00 <br /> (Circle One) <br /> Transfer to Active riactve <br /> Program/Element and Description Record ID Employee iD and Name Status New Owner? Delete <br /> HM-Farm Operations PR0525140 Active Y N A I D <br /> 222 SM HW GEN<5 TONSNR PR0528931 EE0002670-MUNIAPPA NAIDU Active Y N A I D <br /> 40-AST EXEMPT FAC < 1,320 GAL PR0528930 EE0002670-MUNIAPPA NAIDU Active,Exempt Y N A I ^ D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0531565 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,arcVor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed m accordance with all applicable Ordinance Codes and/or Standards and State and+or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: '$25,00= Amount Paid Date / 1 <br /> Water System to be TRANSFERED: Amount Paid Date I I <br /> Payment Type Check Number Received by <br /> Date ?: -.J _I 13Account out: Date 2-1�_1�� <br /> COMMENTS: <br /> 2,iil (AatfjVde) PA <br />