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Date run2/23/201 10:37:36AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 2/23/2015 <br />Record Selection Criteria: Facility ID FA0005995 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0004782 <br />Make changes/corrections in RED ink. <br />q <br />Flaw" <br />INFORMATION CHANGE (date) <br />Owner DBA <br />RAY MULLER <br />OWNERSHIPN <br />CHA GE (date) <br />Number of facilities for this <br />owner : 1 <br />SSN /Fed Tax ID : <br />Owner ID <br />OW0004782 <br />New Oyyter ID : <br />Owner Name <br />MULLER, RAYMOND <br />Active <br />Owner DBA <br />RAY MULLER <br />A I D <br />Owner Address <br />9251 S WOLFE RD <br />Y <br />N <br />FRENCH CAMP, CA 95231 <br />EE0002646 - THUY TRAN <br />Home Phone <br />Not Specified <br />N <br />Work/Business Phone <br />Not Specified <br />Z/) �—Zf;7 <br />Mailing Address <br />9251 S WOLFE RD <br />A D <br />FRENCH CAMP, CA 95231f�/z5�'O�/,rr <br />Y <br />Care of <br />A I D <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0005995 10181991 <br />Facility Name <br />MULLER, RAYMOND <br />Location <br />9251 S WOLFE RD <br />FRENCH CAMP, CA 95231/�.z <br />S:riz�Q✓li w� <br />Phone <br />209-982-1482 x0 <br />Mailing Address <br />9251 S WOLFE RD <br />FRENCH CAMP, CA 95231 <br />Care of <br />Location Code <br />99 - UNINCORPORATED P <br />Alt Phone <br />BOS District <br />001 - VILLAPUDUA, CARLOS <br />Fax <br />APN <br />19129001 <br />EMail: <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name2�'/�i�G <br />L� <br />Title <br />Day Phone <br />Q� <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0007527 <br />Mail Invoices to Owner <br />Account Name MULLER, RAYMOND <br />Account Balance as of 2/23/2015: $79.00 <br />Program/Element and Description <br />Record ID <br />1958 - HM -Farm Operations PR0525759 <br />2333 - FARM UST #1 FACILITY - obsolete PR0503855 <br />2830 - AST FAC - SPCC EXEMPT PR0530600 <br />4740 - WASTE TIRE SITE - EXEMPT PR0535692 <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0532122 <br />New Account ID: <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Employee ID and Name <br />Status <br />New Owner? <br />Delete <br />EE D087 �JAMIEDEOSA <br />Active <br />Y <br />N <br />A I D <br />EE000045td <br />Inactive <br />Y <br />N <br />A I D <br />EE0002646 - THUY TRAN <br />Active <br />Y <br />N <br />AI D <br />EE0002622 - BENJAMIN ESCOTTO <br />Inactive <br />Y <br />N <br />A D <br />Inactive <br />Y <br />N <br />A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andror project specific, PHSrEHD hourly charges associated with this facility <br />or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations i e performed in a dance :Date <br />l applicable Ordinance Codes andlor Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <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 Received b _ <br />REHS:—,Date Account out: <br />COMMENTS: <br />os <br />-rvk"V-- �V., <br />