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A Date run 2/18/2010 12:23:19PI SAN J( UIN COUNTY ENVIRONMENTAL HES' I DEPARTMENT Report#5021 <br />Run by 5290 Pagel <br />Facility Information as of 2/18/2 l V <br />Record Selection Criteria: Facility ID FA0017362 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0014203 <br />Owner Name <br />RON BENEDIX <br />Owner DBA <br />RON BENEDIX <br />Owner Address <br />25888 E DODDS RD <br />ESCALON, CA 95320 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />25888 E DODDS RD <br />25888 E DODDS RD <br />ESCALON, CA 95320 <br />Care of <br />ESCALON, CA 95320 <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0017362 <br />Facility Name <br />RON BENEDIX <br />Location <br />25888 E DODDS RD <br />ESCALON, CA 95320 <br />Phone <br />209-838-2650 x0 <br />Mailing Address <br />25888 E DODDS RD <br />ESCALON, CA 95320 <br />Care of <br />Location Codej <br />BOS District <br />APN <br />VV <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />1� <br />`r <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0030244 <br />Mail Invoices to Owner <br />Account Name RON BENEDIX <br />Account Balance as of 2/18/2010: $280.00 <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 />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />444U - awl nvv vr-ry 1D I UNO/ T R F'KUDJU"1 Dl ttUUUZbfU - MUINIANF'A NAIUU Active Y N AI D <br />2223 - AGRICULTURAL HAZ MAT STORAGE FACILPRO525547 Active Y N A D <br />2830 - AST FAC - SPCC EXEMPT PR0530150 EE0002670 - MUNIAPPA NAIDU Active,Exempt Y N A I D <br />ERSC - ELECTRONIC REPORTING SURCHARGE PR0533076 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: <br />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 Received by <br />REHS: Date Z /_�`�/�0 Account out: L,6— Date o2- / <br />COMMENTS: l <br />\\eh-env\envision\reports\5021. rpt <br />