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Date run 10/12/2005 3:56:48F SAN JOA N COUNTY ENVIRONMENTAL HEAL' ')EPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/12/2005 <br /> Record Selection Criteria: Facility ID FA0016498 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0011764 New Owner ID <br /> Owner Name MACHADO, JOE J <br /> Owner DBA <br /> Owner Address 24916 S MANTECA RD <br /> MANTECA, CA 95337 <br /> Home Phone 209-823-6605 <br /> Work/Business Phone Not Specified <br /> Mailing Address 24916 S MANTECA RD <br /> MANTECA, CA 95337 <br /> Care of MACHADO, JOE J <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0016498 <br /> Facility Name LUCKY J DAIRY <br /> Location 22261 S MOUNTAIN HOUSE PKWY <br /> TRACY, CA 95391 <br /> Phone 209-836-2035 <br /> Mailing Address 17529 W GRANT LINE RD <br /> TRACY, CA 95304 <br /> Care of KIMBROUGH, JOANNE <br /> Location Code 99- UNINCORPORATED AREA APN:20906008 <br /> BOS District 005 -ORNELLAS, LEROY SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0029067 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name NEIL O ANDERSON &ASSOC INC (CirdeOne) <br /> Account Balance as of 10/12/2005: $-279.00 <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 PR0524586 EE0000684-MICHAEL INFURNA 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 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 /> APPLICANT'S SIGNATURE: Date <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 by <br /> REHS: Date ! / Account out: Date <br /> COMMENTS: <br /> \\phs-eh sgI-nt\apps\envision s\reports\5021.rpt <br />