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Date�run 2/14/2013 2:52:05PA SAN JO JIN COUNTY ENVIRONMENTAL HEA] DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 2/14/2013 <br />Record Selection Criteria: Facility ID FA0005463 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0004047 <br />Owner Name <br />LONE T4RrE--CREEK VINEYARDS <br />Owner DBA <br />9691 MURPHY RD <br />Owner Address <br />0 <br />Phone <br />KI 66 <br />Home Phone <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />1 <br />Care of <br />L9P,ll.F ���DS <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0005463 <br />Facility Name <br />LONE T-fRE-E-CREEK VINEYARDS* <br />Location <br />9691 MURPHY RD <br />Day Phone 7 6sLZ <br />STOCKTON, CA 95215 <br />Phone <br />209-599-0479 x0 <br />Mailing Address <br />RIPON, C7rT5"!t6 <br />Care of <br />Location Code 99 - UNINCORPORATED P <br />Bos District 004 - VOGEL, KEN <br />APN 20316004 <br />Make changes/corrections in RED ink. 3113 (_7 <br />INFORMATION CHANGE (date) 1 <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID <br />M � (It"'l <br />MIM <br />Site Mitigation Facility <br />p(#, j W <br />Alt Phone <br />Fax �— <br />EMail : r_\ � Q V\) R, -r\ g" C"AI\a < < CO► 1 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION c <br />Contact Name <br />Title Av� <br />Day Phone 7 6sLZ <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0005941 New Account ID: <br />Mail Invoices to Owner Mail Invoices to: Owner / <br />Facility / Account <br />Account Name LONE TREE CREEK VINEYARDS i (Circle <br />Account Balance as of 2/14/2013: $266.00 C e % + 2 t 3 <br />0* <br />pkv <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status <br />New Owner? Delete <br />1958 - HM -Farm Operations PR0525794 Active <br />Y N A I D <br />2220 - SM HW GEN <5 TONS/YR PR0530336 EE0002670 - MUNIAPPA NAIDU Active <br />Y N A I D <br />2381 - UST FACILITY (BEFORE 1/84) - obsolete PR0502479 EE0000008 - LETITIA BRIGGS Inactive <br />Y N A I D <br />2830 - AST FAC - SPCC EXEMPT PRO530332 EE0002670 - MUNIAPPA NAIDU Active, Exempt <br />Y N A I D <br />4740 - WASTE TIRE SITE - EXEMPT PRO530666 EE0007379 - AMANDA BOERTIEN Active <br />Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCH,PR0534344 Inactive <br />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 andfor <br />Standards and State and/or <br />Federal Laws. <br />yeky 66-T &,A-- 146 Date � / 2 / 3 <br />APPLICANT'S SIGNATURE: /v�el <br />Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment [�e Check Number ReceiP—L <br />REHS: Date / / Account out: Dater <br />COMMENTS: <br />/7/�7 <br />