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Date run 3/14/2011 9:48:50AN SAN JOF'"UIN COUNTY ENVIRONMENTAL HEAL ' q DEPARTMENT Report#5021 <br /> Run by 5290 Pagel <br /> Facility Information as of 3/14/20, . <br /> Record Selection Criteria: Facility ID FA0017238 <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 OW0014079 New Owner ID <br /> Owner Name HENRY G EILERS RANCH <br /> Owner DBA HENRY G EILERS RANCH <br /> Owner Address 16657 E MILTON RD <br /> LINDEN, CA 95236 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 16657 E MILTON <br /> LINDEN, CA 95236 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017238 <br /> Facility Name HENRY G EILERS RANCH 44 4 4,14 <br /> Location 15573 E MILTON RD <br /> LINDEN, CA 95236 <br /> Phone 209-462-6713 x0 <br /> Mailing Address 16657 E MILTON RD n /:4 ifo � <br /> LINDEN, CA 95236 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 10505009 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 AR0030120 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name HENRY G EILERS RANCH (Circle One) <br /> Account Balance as of 3/14/2011: $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 /> 2223-AGRICULTURAL HAZ MAT STORAGE FACILPRO525423 Inactive Y NA I D <br /> 2830-AST FAC -SPCC EXEMPT PRO530312 EE0009488-JEFFREY WONG Active,Exempt Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPRO534274 Inactive <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 Ordinace Codes and/or Standards and <br /> State and/or 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 Receiv y <br /> REHS: Date / / Account out: Date 1 /� <br /> COMMENTS: <br /> \\e h-env\envis ion\reports\5021.rpt <br />