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'Date-run'# 2/9/2011 4:15:43PM SAN JC: ;IN COUNTY ENVIRONMENTAL HEA' 'DEPARTMENT Report#5021 <br /> Run by x Paget <br /> 'Facility Information as of 2/91201T' <br /> Record Selection Criteria: Facility ID FA0016955 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION FUL-11 SSN 1 Fed Tax ID <br /> Owner ID OW0013796 New Owner ID <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 P9-B6ya09 P • by�, ! 3 O D <br /> 6 L_ SCo-f G*A' 9 52;3'1. - 1360 <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 P-0-BOX-4109 <br /> R 366 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 005--ORNELLAS, LEROY Fax <br /> APN 24513017 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 AR0029837 New Account ID: <br /> Mail Invoices to Owner Mail4rivoioes to: Owner I Facility 1 Account <br /> Account Name SKS ENT (Circle One) <br /> Account Balance as of 21912011: $280.00 <br /> (Circle One) <br /> Transfer to Acbvellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner Delete <br /> 2220-SM HW GEN<5 TONSIYR PR0528931 -EE0002670-MUNIAPPA NAIDU Active Y N A I D <br /> 2223-AGRICULTURAL-HAZ;MAT STORAGE-FACILPRO525140 Active Y N A I D <br /> `2840-AST EXEMPT FAC <1,320 GAL PRO528930 EE000267G-MUNIAP.PA NAIDU Active,Exempt Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PRO531565 Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT:.I,the undersigned owner,operator or agent of same,ackndwledge that all site,and/or project specific,PHSIEHD hourly charges associated with this <br /> facility or activity will be billed to the party identified as the OWNER on this form. 'I also certify that ail operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNAT URE: s e� <br /> Program Records to be TRANSFERED: •$25-00= Amount Paid Date' 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 ! <br /> Payment Type Check Number Received b <br /> REHS: Date ! / Account out: Date <br /> COMMENTS: <br /> Heh-env\envision\reportsk502l.rpt <br />