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Date run 3/11/2011 2:08:00Ph SAN JOfINCOUNTY ENVIRONMENTAL HEADEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/11/2 <br /> Record Selection Criteria: Facility ID FA0012033 <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 OW0007072 Case Number: H00814 New Owner ID : <br /> Owner Name C �`�;'rid\10. Q1�-c� �..rn2v:Gam ZN-V— <br /> Owner DBA <br /> Owner Address 0. <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 500 E LOUISE AVE <br /> LATHROP, CA 95330 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012033 <br /> Facility Name �l� c fin-... �i u .nn-rr <br /> Location 500 E LOUISE AVE <br /> LATHROP, CA 95330 <br /> Phone 209-858-629^>• (oag 0 <br /> Mailing Address 500 E LOUISE AVE <br /> LATHROP, CA 95330 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District 003- BESTOLARIDES Fax <br /> APN 19812006 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name S <br /> Title <br /> Day Phone 2 _ _ <br /> Night Phone 209-858-54-64- <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR001912O NewAccount ID: <br /> Mail Invoices to Facility \ Mail Invoices to: Owner / Facility / Account <br /> Account Name L C D yvco-r CZ-.Q-r v ��V�\c C+p3(Cir a One) <br /> Account Balance as of 3/11/2011: $0.00 J <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2960-RWOCB SITE PR0009276 EE0007479-ROOWE ,n Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned oymer,operator or agent of same,acknowledgle that/all site,and/or project specific.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 and/or 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 <br /> Payment Type Check Number —Received rby <br /> REHS: ?_(AM446A Date / ! Account out: v Date <br /> COMMENTS: <br /> \\e h-env\envision\reports\5021.rpt <br />