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Date run 7/8/2009 1:48:01PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL 1-1 DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 7/8/2009 <br />Record Selection Criteria: Facility ID FA0016940 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0013781 <br />Owner Name <br />RALPH ROOS <br />Owner DBA <br />RALPH ROOS <br />Owner Address <br />22742 S �ftftPHY <br />Phone <br />RIPON, CA 95366 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />22742 S MURPHY <br />Location Code <br />RIPON, CA 95366 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0016940 <br />Facility Name <br />RALPH ROOS <br />Location <br />22742 S-PAk+RF4+Y <br />RIPON, CA 95366 <br />Phone <br />209-599-2862 x0 <br />Mailing Address <br />22742 S *tttRPF{Y <br />RIPON, CA 95366 <br />Care of <br />Location Code <br />BOS District <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0029822 <br />Mail Invoices to Owner <br />Account Name RALPH ROOS <br />Account Balance as of 7/8/2009: $0.00 <br />Program/Element and Description <br />Record ID Employee ID and Name <br />2223 - AGRICULTURAL HAZ MAT STORAGE FACILPRO525125 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID <br />00 a <br />MA /V <br />Alt Phone <br />Fax <br />EMail : <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Status New Owner? Delete <br />Active 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 <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: <br />Program Records to be TRANSFERED: * $20.00 = Amount Paid <br />Water System to be TRANSFERED: * $372.00 = Amount Paid <br />Payment Type Check Number <br />REHS: lv Date/�/0 Account out: <br />COMMENTS: <br />U 1, <br />\\eh-env\envision\reports\5021. rpt <br />Date <br />Date <br />Date <br />Receive <br />Date <br />