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Date run <br />Run by 8/13/2004 11:33:27AI <br />Record Selection Criteria: <br />OWNER FILE INFORMATION <br />SAN N UIN COUNTY ENVIRON <br />�i MENTAL HE! -I DEPARTMENT Report »soil <br />Facility Information as of 8/13/2 <br />°A0009917 Pagel <br />Owner ID <br />Owner Name <br />OW0007917 Case Number: H05810 <br />PAT & CHERYL MITCHELL <br />Owner DBA <br />PAT & CHERYL MITCHELL <br />Owner Address <br />Home Phone Not Specified <br />Work/Business Phone 209-931-9502 <br />Mailing Address 1250 E LATHROP RD <br />Care of LATHROP, CA 95330 <br />FACILITY FILE INFORMATION <br />FacilityID FA0009917 <br />Facility Name CALIFORNIA NATURAL PRODUCTS <br />Location 1250 E LATHROP RD <br />LATHROP, CA 95330 <br />Phone 209-858-2525 <br />Make changes/corrections in RED ink or pencil. <br />INFORMAT�I.O GE da <br />OWNERS J'AI ) tl D <br />E a <br />New Owner ID <br />Site Mitigation Facility <br />Mailing Address PO BOX 1219 <br />LATHROP, CA 95330 <br />Care of PAT MITCHELL <br />Location Code APN:198-040-01-0 <br />BOS District 003 - MOW, VICTOR SIC Code:9900 <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0016917 New Account ID: <br />Mail Invoices to Facility Mail Invoices to: Owner / <br />Facility / Account <br />Account Name CALIFORNIA NATURAL PRODUCTS <br />(Circle One) <br />Account Balance as of 8/13/2004: $0.00 <br />(Circle One) <br />Transfer to Active/Ioagwe <br />Program/Element and Description Record ID Employee ID and Name Status <br />New Owner? Delete <br />2220 - SM HW GEN <5 TONS/YR PR0517883 EE0008317 - RAYMOND VON FLUE Active <br />Y N A I D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATIO PRO512205 EE0000000 - HAZ MAT SJC DES Active <br />Y N A I D <br />2244 - PACT TRANSFER RECORD - DES PR0519959 EE0000000 - HAZ MAT SJC DES Active <br />Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SERVICE FPR0509917 EEOOo0000 - HAZ MAT SJC DES 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, andlor project specific, PHS/EHD <br />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 Ordinate <br />Codes andlor Standards and <br />State and/or Federal Laws. <br />APPLICANT'S SIGNATURE: Date <br />Program Records to be TRANSFERED: ' $20.00 = Amount Paid Date <br />Water System to be TRANSFERED: ' $155.00 = Amount Paid Date <br />Payment Type Check Number Received by <br />✓ <br />REHS: f l r (f — Date _!R Account out: Date / <br />/ <br />COMMENTS. <br />\\Phschsq I-nt\apps\Envisions\Reports\5021.rp1 <br />