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Date Iran 12/28/201210:09:03/ SAN JO IN COUNTY ENVIRONMENTAL HEA Report#5021 <br /> DEPARTMENT Pagel <br /> Run by <br /> Facility Information as of 12/28/2012 <br /> Record Selection Criteria: Facility ID FA0021627 <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 OW0017785 New Owner ID <br /> Owner Name TAYLOR, CLIFTON <br /> Owner DBA CITY OF LATHROP CROSSROADS WWTP <br /> Owner Address 1508 EUREKA RD STE 140 <br /> ROSEVILLE, CA 95661 <br /> Home Phone 916-782-3330 <br /> Work/Business Phone Not Specified <br /> Mailing Address 1508 EUREKA RD STE 140 <br /> ROSEVILLE, CA 95661 <br /> Care of TAYLOR, CLIFTON <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0021627 <br /> Facility Name CITY OF LATHROP CROSSROADS WWTP <br /> Location 1501 D'ARCY PKWY <br /> LATHROP, CA 95330 <br /> Phone <br /> Mailing Address 390 TOWNE CENTRE DR <br /> LATHROP, CA 95330 <br /> Care of <br /> Location Code 07- LATHROP Alt Phone <br /> BOS District 003 - BESTOLARIDES Fax <br /> APN Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> contact Name CLIFTON TAYLOR <br /> Title VICE PRESIDENT <br /> Day Phone 916-782-3330 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0039187 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name TAYLOR, CLIFTON (Circle One) <br /> Account Balance as of 12/28/2012: $0.00 <br /> (Circle One) <br /> Transfer to Activellni <br /> PrograMElement and Description Record ID Employee ID and Name Status Naw Owner? Delete <br /> 2950-ENVIRON ASSESS PRO537563 EE0001699-JOHNNY YOAKUM Active Y N A 1 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ander project specific,PHS/EHD hourly charges associated with this facility <br /> or adivity 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 Ordinance Codes an or Standards and State ander <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 /> RENS: Date_/ /_ Account out: Date <br /> COMMENTS: <br />