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Date run 2/23/2012 11:52:41AI SAN JO' 1UIN COUNTY ENVIRONMENTAL HEA' I DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/23/20 t4 <br /> Record Selection Criteria: Facility ID FA0006072 <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 ID OW0004843 New Owner ID <br /> Owner Name PANERO, RHYS K <br /> Owner DBA PANERO FARMS <br /> Owner Address 1 1� Z�1C , <br /> Z74 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address kCA-7� <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0006072 <br /> Facility Name PANERO FARMS <br /> Location 11935 S VAN ALLEN RD <br /> ESCALON, CA 95320 <br /> Phone 209-551-5911 x0 <br /> Mailing Address <br /> vODE&Tr� ne neocc . zzz <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 20515043 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 AR0007561 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name PANERO, RHYS K (Circle One) <br /> Account Balance as of 2/23/2012: $280.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONSNR PR0529981 EE0002670-MUNIAPPA NAIDU Active Y N A I D <br /> 2223-AGRICULTURAL HAZ MAT STORAGE FACILPRO525921 Active Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0504089 EE0007289-ALISON YOUNGBLOOD Inactive Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PR0529980 EE0002670-MUNIAPPA NAIDU Active,Exempt Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPR0534614 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: Date ! / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date ! / <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Re e v by 'f <br /> REHS: Date I l Account out: --� Date <br /> COMMENTS: 1A p IJI qR 7) <br /> C' zvpu' � <br /> 1\eh-env\envision\reports\5021.rpt 0 tie-1 <br />