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Date run 3/12/2015 8:50:43AA SAN JC UIN COUNTY ENVIRONMENTAL HEA I DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/12/2015 <br /> Record Selection Criteria: Facility ID FA0006257 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN/Fed Tax ID <br /> Owner ID OW0004299 New Owner ID <br /> Owner Name LUCCHETTI, VERNON <br /> Owner DBA LUCCHETTI, VERNON <br /> Owner Address 17170 E FRONT ST <br /> LINDEN, CA 95236 <br /> Home Phone 209-931-2601 <br /> Work/Business Phone 209-931-2601 <br /> Mailing Address 17170 E FRONT ST <br /> LINDEN, CA 95236 <br /> Care of LUCCHETTI, VERNON <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA000621 10182063 <br /> Facility Name LUCCHETTI, VERNON <br /> Location 19946 FLOOD RD <br /> LINDEN, CA 95236 <br /> Phone 209-931-2601 <br /> Mailing Address 17170 E FRONT ST <br /> LINDEN, CA 95236 <br /> Care of LUCCHETTI, VERNON <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 10519003 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name LUCCHETTI, VERNON <br /> Title <br /> Day Phone 209-931-2601 <br /> Night Phone 209-931-2601 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0007424 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name LUCCH VERNON (Circle One) <br /> Account Balance as of 3/12/201 $26.00 .�`"1;Kkg— <br /> (Circle One) <br /> Transfer to Active/Inacive <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2332-EXEMPT TANK FACILITY PR0504603 EE0000008-LETITIA BRIGGS Inactive Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PR0530285 EE0009488-JEFFREY WONG Active Y N A C't 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 facility <br /> 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 Ordinance Codes and/or Standards and State and/or <br /> 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 Received y <br /> REHS: MA n4,9loy'4 ` Date/ / Z /—LLAccount out: Date <br /> COMMENTS: <br /> ° � ,�� ���'� %�%'�-� 1 -7 .Z � �- -� cam+-�-►-�� ��-�`� <br />