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Date run y/5/2012 11:18:55AM SAN JOA"UIN COUNTY ENVIRONMENTAL HEAL.rq DEPARTMENT Report#5021 <br />Run by 5290 Pagel <br />Facility Information as of 3/5/20',_ <br />Record Selection Criteria: Facility ID FA0016907 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0013748 <br />Owner Name <br />ANTHONY DELUCCHI <br />Owner DBA <br />ANTHONY DELUCCHI RANCH <br />Owner Address <br />1510 N INLAND DR <br />Phone <br />STOCKTON, CA 965206 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-464-6748 <br />Mailing Address <br />1510 N INLAND DR <br />Location Code <br />STOCKTON, CA 965206 <br />Care of <br />(Circle One) <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0016907 <br />Facility Name <br />ANTHONY DELUCCHI RANCH <br />Location <br />1510 N INLAND DR <br />Facility / <br />STOCKTON, CA 965206 <br />Phone <br />209-464-6748 x0 <br />Mailing Address <br />1510 N INLAND DR <br />Account Balance as of 3/5/2012: $280.00 <br />STOCKTON, CA 965206 <br />Care of <br />Location Code <br />BOS District <br />APN 13124001 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Fax <br />EMail : <br />1, <br />iEiL�M I WE <br />Account ID AR0029789 <br />New Account ID: <br />: <br />Mail Invoices to Owner <br />Mail Invoices to: Owner / <br />Facility / <br />Account <br />Account Name ANTHONY DELUCCHI <br />(Circle One) <br />Account Balance as of 3/5/2012: $280.00 <br />(Circle One) <br />Transfer to <br />Active/Inactve <br />Program/Element and Description Record ID <br />Employee ID and Name Status <br />New Owner? <br />Delete <br />2220 - SM HW GEN <5 TONS/YR PR0530882 <br />EE0001421 -STACY RIVERA Active <br />Y N <br />A I D <br />2223 - AGRICULTURAL HAZ MAT STORAGE FACILPRO525092 <br />Active <br />Y N <br />A D <br />2830 - AST FAC - SPCC EXEMPT PR0530881 <br />EE0001421 - STACY RIVERA Active,Exempt <br />Y N <br />A D <br />ERSC - ELECTRONIC REPORTING STATE SURCHPR0533508 <br />Active <br />Y N <br />�I <br />A (, t ,l D <br />eddd <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges <br />associatedwith this <br />facility or activity will be billed to the party identified as the OWNER on this form. I also <br />certify that a operations will be performed in accordance with all applicable Ordinate <br />Codes and/or Standards and <br />State and/or Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: " $25.00 = <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />REHS: Date <br />COMMENTS: <br />\\eh-env\envision\reports\r2lrpt <br />Date <br />Amount Paid Date <br />_ Amount Paid Date / / <br />DIP l /6 <br />Received by <br />Account out: IA Date 3 15 <br />P�-s -T S� <br />rrn S fv <br />