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Date run 12/26/2008 12:39:46F SAN JOAOTTIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 715021 <br /> Run by <br /> Facility Information as of 12/26/20( Paget <br /> Record Selection Crum, Facility ID FA0015246 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> SSN/Fed Tax ID <br /> Owner ID OW0012223 New Owner ID <br /> Owner Name JEPSEN WEBB RANCH LLC <br /> Owner DBA JEPSEN WEBB RANCH LLC <br /> Owner Address 7200 W 11TH ST <br /> TRACY, CA 95377 <br /> Home Phone 209-835-9491 <br /> Work/Business Phone Not Specified <br /> Mailing Address 7200 W 11TH ST j <br /> TRACY, CA 95377 <br /> Care of KAGEHIRO, RUSSELL <br /> FACILITY FILE INFORMATION <br /> Site Mitigation Facility <br /> Facility ID FA0015246 <br /> Facility Name MUSCO OLIVE-OFF$ITE <br /> Location 17950 W VIA NICOLO RD <br /> TRACY, CA 95377 <br /> Phone <br /> Mailing Address 7200 W 11TH ST <br /> TRACY, CA 95377 <br /> Care of KAGEHIRO, RUSSELL <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 005-ORNELLAS, LEROY Fax <br /> APN 20911032 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0026232 New Account ID: <br /> Mail Invoices to Account Mail Invoices�to: Owner / Facility / Account <br /> Account Name N <S LTANTS Se �� 4�1�oJ� (Circle One) <br /> Account Balance as of 12/26/2008: $0.00 a e ss e _ <br /> (Circle Ona) <br /> Program/Element and Description Record ID Employee ID and NameStatus Transfer to Active/Inactve <br /> New Omer? Delete <br /> 2950-ENVIRON ASSESS PRO522383 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,andlor project speck,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 Ordinate Codes and/or Standards and <br /> Slate and/or Federal Laws. C <br /> APPLICANTS SIGNATURE: 2 c q q p,� 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: u V fr Date <br /> COMMENTS: <br /> \\eh-env\envision\Reports\5021.rpt <br />