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Date run 11/9/2010 11:42:09AI SAN JOA#IN COUNTY ENVIRONMENTAL HEAL Pagel DEPARTMENT <br /> Report#5021 <br /> Run by 1 Facility Information as of 11/9/20 <br /> Record Selection Criteria: Facility ID FA0012758 <br /> Make changes/corrections in RED ink. <br /> ILINFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID GNV0 O0e3zt5 New Owner ID : <br /> Owner Name C I�i U Wvin,IICC P Vt ccC PV-oWS5sOY-s <br /> Owner DBA <br /> Owner Address D / PCS v?,a K 15 <br /> M0 G 5 c 5-S5- <br /> Home <br /> SSHome Phone $-�6fi 65$0 <br /> Work/Business Phone 20a Q49-4�1 <br /> Mailing Address 942 S STOCKTON AVE '4' 5a M <br /> RIPON, CA 95366 <br /> Care of N.F-E C <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012758 <br /> Facility Name FOX RIVER PAPER CO / s+-a ^1� f!rc'cx scars of 2iM I� <br /> Location 942 S STOCKTON AVE <br /> RIPON, CA 95366 <br /> Phone - CttI — ZoT'A�s05� <br /> Mailing Address 942 S STOCKTON AVE <br /> RIPON, CA 95366 <br /> Care of / S ey6.5:- -elr <br /> Location Code (- Alt Phone <br /> BOS District ^ Q <br /> 005-ORNELLAS, LEROY Fax <br /> APN a 5 1 S'i D\Z EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name / Abe,►e1' <br /> Title <br /> Day Phone 24()�n��� <br /> Night Phone 209-69g-42,44 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0021327 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name FOX RIVER PAPER CO (Circle One) <br /> Account Balance as of 11/9/2010: $0.00 <br /> (Circle One) <br /> Transfer to Active/lnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New OwneR Delete <br /> 2965-WATER QUALITY SITE PROJECT PR0516727 EE0006219-LORI DUNCAN 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: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: C-LA' �n.w�r D�In Date 1 l /_L/�G Account out: Date <br /> COMMENTS: <br /> \\eh-env\envis ion\reports\5021.rpt <br />