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nota no 318/2010 8-47:43AM SAN JV 7UIN COUNTY ENVIRONMENTAL HEA' —fl DEPARTMENT Report#5021 <br /> Pagel <br /> Run by <br /> r Facility Information as of 3/8/20'Tr <br /> Record Selection Cmena: Facility ID FA0010824 <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 OW0008822 New Owner ID <br /> Owner Name VINTAGE PRODUCTION CA LLC <br /> Owner DBA <br /> Owner Address PO BOX 459 <br /> WOODLAND, CA 95776 <br /> Home Phone Not Specifie <br /> Work/Business Phone 916-661 66 dal 3-IL �1�2 <br /> Mailing Address PO)idX 609 <br /> RIO VISTA, 945711230 <br /> Care of ' <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010824 <br /> Facility Name VINTAGE PRODUCTION CA LLC <br /> Location 12350 S CROCKER RD <br /> STOCKTON, CA 95206 <br /> Phone 707-374-6428 <br /> Mailing Address 9600 MING AVE STE 300 j _5 YYIq �r <br /> BAKERSFIELD, CA 93311 I-tn V'i y'7L ce <br /> Care of ACCOUNTS PAYABLE <br /> Location Code 99- UNINCORPORATED A Aft Phone <br /> BOS District 003- BESTOLARIDES Fax 2/07 3-7LI G <br /> APN 191-040-02 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 AR0017824 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility I Account <br /> Account Name VINTAGE PRODUCTION CA LLC (Circle One) <br /> Account Balance as of 3/8/2010: $262.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> PrograMElement and Description Record ID Employee ID and Name Status New Oymer? Delete <br /> 2220-SM HW GEN<5 TONS/YR PRO517954 EE0001421 -STACY RI VERA Active Y N AIie� D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO513112 EE0000000-HAZ MAT SJC OES Inactive Y N A --f- D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPR0510824 EE0000000-HAZ MAT SJC OES Inactive Y N A &D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PRO532473 Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknovAedge that all site,and/or project spec,PHS/EHD hourly charges associated with this <br /> reality or activity wig be billed to the party identified as the OWNER on this form. I also certify that all operations voll be performed in accordance with all applicable Ordinance Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANTS SIGNATURE: Dale / I <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Receive' y <br /> REHS: Date / / Account out: Date / l o <br /> COM.7E1(T �1 <br /> L14— <br /> I%eh-envtenNsion4eporls15021.rpt <br />