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Date run 1/22/2010 8:32:34AN SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Neponsoun Run by 5290 Paget Facility Information as of 1/22/20 Record Selection Criteria: Facility ID FA0003410 OWNER FILE INFORMATION Owner ID OW0002534 Case Number: 016193 Owner Name VAN EGMOND, GERARD C Owner DBA VAN EGMOND, G C (GREENDALE) Owner Address 8220 E LIBERTY RD Employee ID and Name Status GALT, CA 95632 Home Phone Not Specified Work/Business Phone 209-334-9118 Mailing Address 8220 E LIBERTY RD I D GALT, CA 95632 Care of VAN EGMOND, GERARD C FACILITY FILE INFORMATION Facility ID FA0003410 Facility Name VAN EGMOND, G C (GREENDALE) Location 8220 E LIBERTY RD EE0001422 - ARIS CACAPIT Active,Exempt GALT, CA 95632 Phone 209-334-9118 Mailing Address 8220 E LIBERTY RD Y GALT, CA 95632 Care of VAN EGMOND, GERARD C Location Code 99 - UNINCORPORATED P BOS District 004 - VOGEL, KEN APN 00703027 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name VAN EGMOND, GERARD C Title Day Phone 209-334-9118 Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0002987 Mail Invoices to Facility Account Name VAN EGMOND, G C (GREENDALE) Account Balance as of 1/22/2010: $0.00 Program/Element'and Description Record ID 2011 - GRADE A DAIRY PR0200140 2220 - SM HW GEN <5 TONS/YR PRO530459 2223 - AGRICULTURAL HAZ MAT STORAGE FACILPRO525946 2830 - AST FAC - SPCC EXEMPT PRO530458 4620 - DAIRY - WATER SUPPLY WA0515671 Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : lo' Ake [I�`�i gc'_ Alt Phone Fax EMail : New AccountlD: : Mail Invoices to: Owner / Facility / Account (Circle One) 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: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number REHS: COMMENTS: \\eh-env\envision\reports\5021.rpt Date ! / ' $20.00 = Amount Paid Date ! / * $372.00 = Amount Paid Date Receiv d by Date / / Account out: Date �_lpLo�l1� e ti,5 5 (Circle One) Transfer to Active/Inactve Employee ID and Name Status New Owner? Delete EE0004589 - KADEANNE LINHARES Active Y N A I D EE0001422 - ARIS CACAPIT Active Y N A I D Active Y N A I D EE0001422 - ARIS CACAPIT Active,Exempt Y N A I D EE0004589 - KADEANNE LINHARES 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: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number REHS: COMMENTS: \\eh-env\envision\reports\5021.rpt Date ! / ' $20.00 = Amount Paid Date ! / * $372.00 = Amount Paid Date Receiv d by Date / / Account out: Date �_lpLo�l1� e ti,5 5