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Date fun 1/10/2013 3:33:3110I SAN JC UIN COUNTY ENVIRONMENTAL HEA' 1 DEPARTMENT ReponM21 <br /> Run by �I► I Pagel <br /> Facility Information as of 1/10/2013 <br /> Record Selection Criteria: Facility ID FA0017534 <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 lD OW0014375 New Owner ID <br /> Owner Name BESSIE A& RICHARD REYNOLDS TR <br /> Owner DBA BESSIE A& RICHARD REYNOLDS TR <br /> Owner Address 7045 COX RD <br /> LINDEN, CA 95236 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 69 <br /> LINDEN, CA 95236 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017534 <br /> Facility Name BESSIE A& RICHARD REYNOLDS TRUST P <br /> Location 7045 COX RD <br /> LINDEN, CA 95236 <br /> Phone 209-887-3074 x0 <br /> Mailing Address PO BOX 69 <br /> LINDEN, CA 95236 <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 09124042 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 AR0030416 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name BESSIE A& RICHARD REYNOLDS TR (circle one) <br /> Account Balance as of 1/10/2013: $0.00 <br /> ((orae One) <br /> Transfer to Aellvalinactve <br /> PrograMElement and Description Record ID Employee ID and Name Status New OwneO Delete <br /> HM-Farm Operations PRO525719 Active Y N A @ D <br /> CL840>AST EXEMPT FAC < 1,320 GAL PR0529541 EE0000753-WILLY NG Active,Exempt Y N A I D <br /> SC-ELECTRONIC REPORTING STATE SURCH,PR0531813 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator"agent m same,admowiadge that all site,ars'"proiea speafic.PHS/EHD hourly charges acs"iated with INs faality <br /> or saiwi,will be belled to the party identified as the OWNER on this form I also cenily,that all operations will be performed in accordance with all applicable Ordinance Codes and"Standards and State and" <br /> Federal laws <br /> APPLICANTS SIGNATURE. Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / I_ <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Re _ <br /> REHS: 7� — Date l /6'! i3 Account out: M1 Date / I <br /> COMMENTS <br />