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Date run 6/15/201012:51:42PI SAN JOA(W COUNTY ENVIRONMENTAL HEAL-EPARTM ENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 6/15/2010 <br /> Record Selection Criteria: Facility ID FA0020197 <br /> Make changes/corrections in RED ink. <br /> Fit" INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0016591 New Owner ID <br /> Owner Name DELTA FARMS RECLAMATION DIST <br /> Owner DBA <br /> Owner Address 421 S EL DORADO ST STE <br /> STOCKTON, CA 95203 <br /> Home Phone 916-761-1282 <br /> Work/Business Phone 916-456-4400 <br /> Mailing Address 421 S EL DORADO ST STE E <br /> STOCKTON, CA 95203 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0020197 Lo S <br /> Facility Name OJECT i.>.b W 5 � <br /> Location +69W W RIG= hill C on SFE <br /> S-TQQXTQW-, G*-4-�5219 3 <br /> Phone Q46-7ai_1989 XC€61— ,O`L,5 — s-i'vt <br /> nVv <br /> Mailing Address 424 8 F EiE) n <br /> n ST STF r ?SJo o-u tb i't/V ,L <br /> ST 95203 "iaVrok I 5 <br /> Care of ty\t" Ca L,ujn,d-L^ <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 06909032 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 AR0036067 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name PRESTON PIPELINES (Circle One) <br /> Account Balance as of 6/15/2010: $-115.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner/ Delete <br /> 2950-ENVIRON ASSESS PR0534931 EE0003611 -FRANK GI RARDI 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 spec,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 andror Federal Laws. <br /> APPLICANT'S SIGNATURE:- Date �p <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 Received r.eTd by <br /> REHS: Date / / Account out: \f Date / k5 / 1C) <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />