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Date run i2/20/2011 11:26:25AI SAN JO' UIN COUNTY ENVIRONMENTAL HEAL' DEPARTMENT Report 45021 <br /> Run by Tom/ `4 Pagel <br /> Facility Information as of 2/2012013 <br /> Record Selection Criteria: Facility ID FA0017175 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0014016 New Owner ID <br /> Owner Name RICHARD BONOTTO <br /> Owner DBA RICHARD BONOTTO <br /> Owner Address 3294 W SARGENT RD -41,2 l LINu xu <br /> LODI, CA 0&242--95aqv- ? 4? <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 3294 W SARGENT RD /n l} 1 -awme `-, <br /> LODI, CA-952# q.SoZ�d -,�q/p w <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017175 <br /> Facility Name RICHARD BONOTTO <br /> Location 3294 W SARGENT RD <br /> LODI, CA 95242 <br /> Phone 209-368-2469 x0 <br /> Mailing Address 3294 W SARGENT RD to IJ( S <br /> LODI, CA 4522� <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 02514010 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 AR0030057 New Account Ill <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility ! Account <br /> Account Name RICHARD BONOTTO (Circle One) <br /> Account Balance as of 2/20/2013: $53.00 <br /> (Circle One) <br /> Transfer to Activa9nactve <br /> P rdElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> V- M-Farm Operations PRO525360 Active Y N A I D <br /> B4 ST EXEMPT FAG <1,320 GAL PR0529576 EE0000753-WILLY NG Active,Exempt Y N A I D <br /> C-ELECTRONIC REPORTING STATE SURCHPR0532044 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project speck,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 in accordance with all applicable Ordinance Codes and/or Standards and State andror <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date 1 ! <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date 1 ! <br /> Water System to be TRANSFERED: Amount Paid Date / 1 <br /> Payment Type Check Number ReceOy <br /> REHS: Date I I Account out: Date 1 1 <br /> COMMENTS: <br /> �L)� �z1� <br />