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Date run 2/12/2010 10:37:59AI SAN JC AN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/12/201 U <br /> Record Selection Criteria: Facility ID FA0017545 <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 OW0014386 New Owner ID <br /> Owner Name LAGORIO BROS FARMS <br /> Owner DBA LAGORIO BROS FARMS <br /> Owner Address 20001 E FLOOD RD ;L O (LF1 -Flood a2 <br /> LINDEN, CA 95236 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 20001 E FLOOD RD q lliDO <br /> LINDEN, CA 95236 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017545 <br /> Facility Name LAGORIO BROS FARMS <br /> Location r <br /> LINDEN, CA 95236 V`� <br /> Phone 209-887-2141 x0 I <br /> Mailing Address 20001 E FLOOD RD -2-0141 E -Rood <br /> ot <br /> LINDEN, CA 95236 <br /> Care of <br /> Location Code /' 1/ 0� Alt Phone <br /> BOS District f `7 ("� Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION ,,�' �✓V I I15 <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0030427 NewAccount ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name LAGORIO BROS FARMS (Circle One) <br /> Account Balance as of 2/12/2010: $280.00 <br /> (Circle One) <br /> Transfer to Active/lnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0530611 EE0009488-JEFFREY WONG Active Y N A I D <br /> 2223-AGRICULTURAL HAZ MAT STORAGE FACILPRO525730 Active Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PR0530610 EE0009488-JEFFREY WONG Active,Exempt Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PR0533141 Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD 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 all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: "$372.00-r—_,Amount Paid Date <br /> Payment Type ' h --- -- Receivedb <br /> REHS: Date —J Account out: L442_- -DatS` <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />