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Date run 12/11/2012 9:33:38A <br /> SAN JI1WIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 12/11/2012 <br /> Record Selection Criteria: Facility ID FA0000649 <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 OW0000518 New Owner ID : <br /> Owner Name ,J�" ""���r oj�— _ <br /> Owner DBA NF4&T-6E-6t&A-IN5- 1. .. ,r 6tP7S—O��WF1y <br /> Owner Address ZS"9 l L✓KR- <br /> RIPON, CA 953662.74* <br /> Home Phone 209-599-3085 ylDg <br /> Work/Business Phone Not Specified <br /> Mailing Address p <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0000649 <br /> Facility Name NESTLE USA INC Ir\j1G57c I�� —yuG. <br /> Location 230 INDUSTRIAL DR <br /> RIPON, CA 95366 <br /> Phone Q <br /> Mailing Address 800 N BRAND BLVD <br /> GLENDALE, CA 91203 <br /> Care of " ,_, P=tE OAl sn <br /> Location Code 05 - RIPON Alt Phone <br /> BOS District 005-ORNELLAS, LEROY Fax <br /> APN 25938001 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title SZ <br /> Day Phone /Lf,IlErA <br /> Night Phone 1: Nit: * C.0 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000648 New Account ID: <br /> Maillnvoicesto Account Mail Invoices to: Owner / FacilityAccount <br /> Account Name (Circle One) <br /> Account Balance as of 12/11/2012: $-375-66- <br /> (Circle one) <br /> Transfer to Aclivennaclve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2229-GEN 50<250 TONS PERMIT PR0220104 EE0004636-GARRETT BACKUS Inactive Y N A I D <br /> 2231 -HAZARDOUS WASTE PER FACILITY PR0527658 EE0004636-GARRETT BACKUS Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PRO505647 EE0007289-ALISON YOUNGBLOOD Inactive Y N A I D <br /> 2960-RWQCB SITE PROOG9051 EE0000684-MICHAEL INFURNA Active Y N A I D <br /> 4630-NTNC WATER SYSTEM WAG460794 EE0005838-ADRIENNE ELLSAESSEInactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anclor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form I also certify that all operations volt be performed in accordance with all applicable Ordinance Codes and'or Standards and State andfor <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 <br /> COMMENTS: <br />