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a <br /> Dato,run 2/13/2014 11:46:25AI SAN Jl )UIN COUNTY ENVIRONMENTAL HEi 3 DEPARTMENT Report#5021 <br /> Run i•v ' Pagel <br /> Facility Information as of 2/13/2014 <br /> Record Selection Criteria: Facility ID FA0017551 <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 OW0014392 New Owner ID <br /> Owner Name REID ROBERTS <br /> Owner DBA REID ROBERTS <br /> Owner Address 311 E MAIN #202 <br /> STOCKTON, CA 95202 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address l S . Soo.4 u.i n S_� F 3rd <br /> 02 S- oc4-r_ y-,I CA. g S 03 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017551 10,186,629 <br /> Facility Name REID ROBERTS <br /> Location 8001 N CLEMENTS RD <br /> LINDEN, CA 95236 <br /> Phone 209-941-8714 x0 <br /> Mailing Address 311 E MAI N#202 kk S. oar <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 06516014 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 AR0030433 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name REID ROBERTS (Circle One) <br /> Account Balance as of 2/13/2014: $53.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PR0525736 Active Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0529582 EE0000753-WILLY NG Active,I Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532292 Inactive 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 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 Slate 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 Recei <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br />