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Date run 2/19/2014 10:41:43AI SAN JO. AN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 Run by Pagel Facility Information as of 2/19/2014 Record Selection Criteria: Facility ID FA0003410 BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andlor project specific, PHSIEHD 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 Ordinance Codes andfor Standards and Slate and/or Federal Laws. APPLICANT'S SIGNATURE: Date / / Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Re_ elved by / REHS: Date / / Account out: Date / _22)/` COMMENTS: Make changestcorrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) OWNER FILE INFORMATION SSN/Fed Tax ID Owner ID OW0002534 Case Number: 016193 New Owner ID Owner Name VAN EGMOND,GERARD IRV TRST1997 Owner DBA VAN EGMOND, G C (GREENDALE) Owner Address 8220 E LIBERTY RD GALT, CA 95632 Home Phone 209-712-7482 Work/Business Phone Not Specified Mailing Address 8270 E LIBERTY RD O GALT, CA 95632 C1 5L gSla3Z Care of GERARD VAN EGMOND IRV TRST1997 FACILITY FILE INFORMATION Facility ID / CERS ID FA0003410 10,181,143 Facility Name VAN EGMOND, G C (GREENDALE) Location 8220 E LIBERTY RD GALT, CA 95632 Phone 209-712-7482 Mailing Address 8270 E LIBERTY RD GALT, CA 95632 Care of GERARD VAN EGMOND IRV TRST1997 Location Code 99 - UNINCORPORATED P Alt Phone Bos District 004 - VOGEL, KEN Fax APN 00703027 EMail: 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 New Account ID: Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account Account Name VAN EGMOND, G C (GREENDALE) (Circle One) Account Balance as of 2/19/2014: $266.00 (Circle One) Transfer to Active/inactve ProgranUElement and Description Record ID Employee ID and Name Status New Owner? Delete 1958 - HM -Farm Operations PR0525946 Active Y N A I D 2011 - GRADE A DAIRY PR0200140 EE0004589 - KADEANNE LINHARES Inactive Y N A I D 2220 - SM HW GEN <5 TONS/YR PRO530459 EE0001422 - ARIS CACAPIT Active Y N A I D 2830 -AST FAC - SPCC EXEMPT PRO530458 EE0001422 - ARIS CACAPIT Active,l Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARG PRO531862 Inactive Y N A I D 4620 - DAIRY - WATER SUPPLY WA0515671 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, andlor project specific, PHSIEHD 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 Ordinance Codes andfor Standards and Slate and/or Federal Laws. APPLICANT'S SIGNATURE: Date / / Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Re_ elved by / REHS: Date / / Account out: Date / _22)/` COMMENTS: