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Date run 3/18/2015 4:14:22PA SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Repon#5021 <br /> Run by <br /> Facility Information as of 3/18/2015 Paget <br /> Record Selection Catena: Facility ID FA0004500 <br /> Make changes/corrections in RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/FedTaxlD : <br /> Owner ID OW0003415 New Owner ID <br /> Owner Name Valley Crest Companies <br /> Owner DBA VALLEY CREST TREE COMPANY <br /> Owner Address 28915 FUNCK RD <br /> FARMINGTON, CA 95230 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-886-5511 <br /> Mailing Address 28915 FUNCK RD <br /> FARMINGTON, CA 95230 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0004500 10181639 <br /> Facility Name VALLEY CREST TREE COMPANY <br /> Location 28915 FUNCK RD <br /> FARMINGTON, CA 95230 <br /> Phone 209-886-5511 x <br /> Mailing Address 289+55 FanCk-RD ->c �'$9 <br /> FARMINGTON, CA 95230 <br /> Care of Emory Chow <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004-WINN, CHARLES Fax <br /> APN EMail <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0004182 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name VALLEY CREST TREE COMPANY (Circle One) <br /> Account Balance as of 3/18/2015: $292.00 <br /> (Cbde One) <br /> Transfer to Acbvennocive <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner! Delete <br /> /Y958-HM-Farm Operations PRO525793 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2220-SM HW GEN<5 TONSR PR0530613 EE0009488-JEFFREY WONG Active Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PR0530612 EE0009488-JEFFREY WONG Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO535383 EE0009000-HARPRIT MATTU Active Y N A 1 D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534167 Inactivf Y N A I D <br /> 4630-NTNC WATER SYSTEM WA0461343 EE0005838-ADRIENNE ELLSAESSER Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,ecl nowledge that all site,andfor protect specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be tubed to the party identified ea the OWNER on this form. I also codify that all operations wIl be performed in accordance with all applicable Ordinance Codes andfor Standards and State andhor <br /> 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: —) Date 3 / tQ / 1 S <br /> COMMENTS: <br /> M amt � r��-u v ✓� ! �o r� e e P-�-n-C�2 / u,Se �0 3ox ��.t �cnr� <br />