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Date run 2118/2008 11:13:28/ SAN JOJUIN COUNTY ENVIRONMENTAL HEADEPARTMENT Report#5021 <br /> Rugby Pagel <br /> Facility Information as of 12/1812 <br /> Record Selection Criteria: Facility ID FAD017006 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0013847 New Owner ID <br /> Owner Name CANAL RANCH <br /> Owner DBA '-'Ai4At7RA 4aH p PNC <br /> Owner Address 11292 N ALPINE RD <br /> STOCKTON, CA 95212 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified 7"B <br /> Mailing Address 11292 N ALPINE RD <br /> STOCKTON, CA 95212 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017006 <br /> Facility Name CANAL RANCH <br /> Location BLOSSOM RD Z O O <br /> THORNTON, CA 95686 <br /> Phone 209-982-0734 xO <br /> Mailing Address 11292 N ALPINE RD <br /> STOCKTON, CA 95212 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name aTO �RNA�y,J,g T/ <br /> Title Aln 1'Ll A Iyfq /) ''Pt' <br /> a` <br /> Day Phone9 44---moo r7 9 Zee <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> AccountlD AR0029888 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name CANAL RANCH (Circle One) <br /> Account Balance as of 12/18/2008: $0.00 <br /> (Circle One) <br /> Transferto Active/Inaclve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2223-AGRICULTURAL HAZ MAT STORAGE FACILPRO525191 Active 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 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 andlof Standards and <br /> Slate 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= Amount Paid Date—/—/ <br /> Payment Type Check Number Receiv <br /> REHS: [ Date 1/2--"/Account out: <br /> COMMENTS: <br /> \\phs-ehsq I-nt\apps\envisions\reports\5021.rpt <br />