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Date run 4/8/2011 8:29:02AM SAN JC- UIN COUNTY ENVIRONMENTAL HEA' 'I DEPARTMENT Report#5021 <br /> Run by <br /> ~ Facility Information as of 4/8/2011 Paget <br /> Record Selection Criteria: Facility ID FA0014092 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATIONII "( � OWNERSHIP CHANGE(date) <br /> SSN/Fed Tax ID <br /> Owner ID OW0011155 New Owner ID : <br /> Owner Name FONTES, ARLIND fUN('L OlTM7 <br /> Owner DBA <br /> Owner Address ^ 6S8o (i4t4wr <br /> THORNTON, CA 95686 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 53 `p,o- �w Ll Q' <br /> THORNTON, CA 95686 <br /> Care of FONTES, ARLIND <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0014092 <br /> Facility Name FONTES, ARLIND 39-292 SIF 9W\ (NG S - <br /> Location 11665 W BARBER RD <br /> THORNTON, CA 95686 <br /> Phone 2QQ_7Q4_26?.} n <br /> Mailing Address PO BOX 53 46 60V Gla <br /> THORNTON, CA 95686 <br /> Care Of FONTES, ARLIND fidiAc 01w <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 00112001 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone I Ct <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0023829 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name FONTES, ARLIND 39-292 n (Circle One) <br /> Account Balance as of 4/8/2011: $280.00 Do-w� <br /> (Circle One) <br /> Transfer to ActiwilracNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PRO529132 EE0001422-ARIS CACAPIT Active Y N A D <br /> 2223-AGRICULTURAL HAZ MAT STORAGE FACILPRO525827 Active Y N A I D <br /> 2795-EMPLOYEE HOUSING-HISTORICAL CAMPSPRO518716 EE0002646-THUY TRAN Inactive Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PRO529131 EE0001422-ARIS CACAPIT Active,Exempt Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPR0513453 Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undMignad 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 ma 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 andlor 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 Da a <br /> Payment Type Check Number Receiv <br /> RENS: ��t0,1 Date t /_Q_/ tl Account out: Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />