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Date run W27/2012 8:48:52AR SAN JOIN COUNTYENVIRONMENTAL HEA DEPARTMENT <br /> � Report M5021 <br /> Run by 4006 <br /> Facility Information as of 2127/2 Pagel <br /> Record Selection Criteria: Facility ID FA0003875 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> SSN/Fed Tax ID <br /> Owner ID OW0002867 New OwnerlD <br /> Owner Name W%TBERME 4S-IXC Lti1 L ESTA'7r— LL C <br /> Owner DBA LUMBERMEN`87mc <br /> Owner Address 1 00 <br /> S rL>F w A- 98r o 4 <br /> Home Phone NGt�{fjgd <br /> Work/Business Phone 3615-456-8598 <br /> Mailing Address <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0003875 <br /> Facility Name _ F} D —T.1Z C) <br /> Location 11800 S HARLAN RD <br /> LATHROP, CA 95330 <br /> Phone <br /> Mailing Address .Rg-Bgj(—i.76• <br /> eA 953" <br /> Care of SSM <br /> Location Code 07-LATHROP Alt Phone <br /> BOS District 003 - BESTOLARIDES Fax <br /> APN 19603003 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 AR0003463 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name T LLA-S (Circle One) <br /> Account Balance as of 2/27/2012: $0.00 <br /> (Circle One) <br /> Program/Element and Description Record ID Employee ID and NameTransfer to Active/Inactve <br /> Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PR0501821 Active Y N A—ID <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge 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 wrlify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or 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 <br /> COMMENTS: <br /> \\eh-env\envision\reports15021.rpt <br />