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Date run 2/2/2011 2:'10:14PM SAN J JIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> Run by 5290 Pagel <br /> Facility Information as of 2/2/2011 <br /> Record Selection Criteria: Facility ID FA0016710 <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 OW0013551 New Owner ID : <br /> Owner Name NESTER ENT- LOS LOMAS VINEYAR AkSl ' �- - /,d($ /oM a g &4ardJ <br /> Owner DBA NESTER ENT- LOS LOMAS VINEYAR <br /> Owner Address 13852 E PELTIER RD <br /> ACAMPO, CA 95220 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 13852 E PELTIER RD <br /> ACAMPO, CA 95220 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0016710 <br /> Facility Name NESTER ENT- LOS LOMAS VINEYARD AMS4-cr - )-a �DhrLQS 7)Fz4 ' <br /> Location 29250 N MACKVILLE RD �2$501 N. Ma-C" .l,Lc.,- <br /> CLEMENTS, CA 95227 <br /> Phone 209-727-5092 x0 <br /> Mailing Address 13852 E PELTIER RD <br /> ACAMPO, CA 95220 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 00918005 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0029592 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name NESTER ENT- LOS LOMAS VINEYAR (Circle One) <br /> Account Balance as of 2/2/2011: $280.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0530437 EE0001422-ARIS CACAPIT Active Y N A I D <br /> 2223-AGRICULTURAL HAZ MAT STORAGE FACILPRO524895 Active Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PR0530436 EE0001422-ARIS CACAPIT Active,Exempt Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PR0531334 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: 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 Received by <br /> REHS: Date / / Account out: LA6— Date <br /> COMMENTS: <br /> a d d h c/1a �� 1 <br /> 4uu carv,�,�t �►p� �iy <br /> \\eh-env\envision\reports\5021.rpt <br />