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Date ran 1/31/2013 2:21:33PR SAN JC�;UIN COUNTY ENVIRONMENTAL HEA T DEPARTMENT Report#5021 <br /> Run by �J Pagel <br /> Facility Information as of 1/31/2013 <br /> Record Selection Criteria: Facility ID FA0017061 <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 OW0013902 New Owner ID <br /> Owner Name RUSCIGNO ORCHARDS <br /> Owner DBA RUSCIGNO ORCHARDS <br /> Owner Address 29999 S CHRISMAN RD <br /> TRACY, CA 95304 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 28481 <br /> SAN JOSE, CA 95159 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017061 <br /> Facility Name RUSCIGNO ORCHARDS <br /> Location 29999 S CHRISMAN RD <br /> TRACY, CA 95304 <br /> Phone 408-279-8822 x0 <br /> Mailing Address PO BOX 28481 <br /> SAN JOSE, CA 95159 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 25322011 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 AR0029943 NewAccount ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility I Account <br /> Account Name RUSCIGNO ORCHARDS (CirdeOne) <br /> Account Balance as of 1/31/2013: $0.00 <br /> (Circle One) <br /> Transfer to ActivMnactve <br /> Progra"Element and Description Record 10 Employee ID and Name Status New Owner? Delete <br /> M-Farm Operations PR0525246 Active Y N AI D <br /> C2220:AM- M HW GEN<5 TONS/YR PRO530963 EE0002646-THUY TRAN Active Y N A D <br /> -23MAST EXEMPT FAC < 1,320 GAL PRO530962 EE0002646-THUY TRAN Active,Exempt Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0531530 Inactive Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of aame,acknowlecige that ell site,and/or project soacrfic,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party idenhhed as the OWNER on this form I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State and/a- <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date / I <br /> Payment Type Check Number Received c,by <br /> REHS: Date�r�/ Account out: Date 2—/ I / 1 J . <br /> COMMENTS <br /> 2v <br />