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Dati,run '/28/2009 1:02:22PN SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 1/28/2( Record Selection Criteria: Facility ID FA0017345 Make changes/corrections in RED ink or pencil. INFORMATION CHANGE(date) OWNERSHIP CHANGE(date) OWNER FILE INFORMATION SSN/Fed Tax ID D 17 AIL? Owner ID New Owner ID !.() Owner Name CC- 0 ' ` Owner DBA CT Owner Address 1LTON RD E95320 5• Work/Business Phone N Mailing Address 1LTON RD E0, 95320 Care of / --a FACILITY FILE INFORMATIO / SBO I-1 Al Facility ID F 0 1734 Facility Name c// Location 15 99 CARROLTON RD S, t�T fD l ES A ON, CA 95320 kO KJ 02 Phone 20 - 817065 x0 �D�l—< Mailing Address 15 9 S 4RROLTON RD ESCALON, 95320 - Care of Location Code Alt Phone BOS District Fax APN EMail: EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATIO/k Account ID 0030227 New Account ID: Mail Invoices to ( gr Mail Invoices to: Owner / Facility / Account Account Name /1�Q�f/V �N G (Circle One) Account Balance as of 1/28'2009: .00 (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 2223-AGRICULTURAL HAZ MAT STORAGE FACILPRO525530 Active Y N A I D 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 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 State and/or Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: '$20.00= Amount Paid Date Water System to be TRANSFER D: '$372.00= Amount Paid Date Payment Type Check Number Receivedb� REHS: Date _! /C? Account out: Date / COMMENTS: \\eh-env\envision\reports\5021.rpt