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Date run 12/3/2014 2:31:07PN SAN JOE IN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/3/2014 <br /> Record Selection Criteria: Facility ID FA0017516 <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: 1 SSN/Fed Tax ID <br /> Owner ID OW0014357 New Owner ID <br /> Owner Name EUGENE SCHENONE <br /> Owner DBA EUGENE SCHENONE <br /> Owner Address 12441 E COPPEROPOLIS RD <br /> STOCKTON, CA 95215 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 12441 E COPPEROPOLIS RD <br /> STOCKTON, CA 95215 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017516 10186573 <br /> Facility Name EUGENE SCHENONE <br /> Location 12441 E COPPEROPOLIS RD <br /> STOCKTON, CA 95215 <br /> Phone. 0 <br /> Mailing Address 12441 E COPPEROPOLIS RD <br /> STOCKTON, CA 95215 <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 10320026 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 AR0030398 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name EUGENE SCHENONE (Circle One) <br /> Account Balance as of 12/3/2014: $0.00 <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 PR0525701 Active Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PR0529713 EE0009488-JEFFREY WONG Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534398 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 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 TyCheck Number Received by <br /> ivD=:�REHS: Date / / _ Account out: Date <br /> COMMENTS: <br />