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Date run 1/29/2013 11:40:02A1 SAN JC UIN COUNTY ENVIRONMENTAL HEA I DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 1/29/2013 <br /> Record Selection Criteria: Facility ID FA0017374 <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 OW0014215 New Owner ID <br /> Owner Name LONETREE RANCH (VERNON HENDLEY <br /> Owner DBA LONETREE RANCH (VERNON HENDLEY <br /> Owner Address 555 BOB WAY <br /> RIPON, CA 953669587 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 555 BOB WAY <br /> RIPON, CA 953669587 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017374 <br /> Facility Name LONETREE RANCH (VERNON HENDLEY) <br /> Location 18281 LONE TREE RD <br /> ESCALON, CA 95320 <br /> Phone 209-613-4767 x0 <br /> Mailing Address 555 BOB WAY 'Ib5qu f1 orph�j Q. . <br /> RIPON, CA 953669587 ---cLAjAn <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 20505019 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 AR0030256 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name LONETREE RANCH (VERNON HENDLEY (Circle One) <br /> Account Balance as of 1/29/2013: $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 /> ac <br /> HM-Farm Operations PR0525559 Active Y N A I D <br /> ASTFAC -SPCC EXEMPT PR0529969 EE0002670-MUNIAPPA NAIDU Active,Exempt Y N A I D <br /> -ELECTRONIC REPORTING STATE SURCH,PR0534350 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all Site,anclor 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 andor <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 Receive �r <br /> REHS: �Q�O� �°— Date�_/��/� Account out: Date <br /> COMMENTS: <br />