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Date run 5/4/2009 3:04:03PM SAN JO A'IUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by * Pagel <br /> Facility Information as of 5/4/201. <br /> Record Selection Criteria: Facility ID FA0017274 <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 OW0014115 New Owner ID <br /> Owner Name R&J DONDERO <br /> Owner DBA R&J DONDERO <br /> Owner Address 16299 E HWY 26 <br /> LINDEN, CA 95236 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 16299 E HWY 26 <br /> LINDEN, CA 95236 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017274 <br /> Facility Name R&J DONDERO <br /> Location 20120 E COPPEROPOLIS RD <br /> LINDEN, CA 95236 <br /> Phone 2.0-994-2E+1 x0 n <br /> Mailing Address 16299-E-I•'W*-26 <br /> LC 2� 3� <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 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 AR0030156 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name R&J DONDERO (Circle One) <br /> Account Balance as of 5/4/2009: $213.00 <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 TONS/YR PR0529707 EE0009488-JEFFREY WONG Active Y N A I D <br /> 2223-AGRICULTURAL HAZ MAT STORAGE FACILPRO525459 Active Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PR0529706 EE0009488-JEFFREY WONG Active,Exempt 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 Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> 1 <br /> APPLICANT'S SIGNATURE: SEE EYP Ci,�� ����-�- � `�'�` Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: �Z Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />