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Date ran 9/22/2011 9:54:02AK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by 1273 Pagel <br /> Facility Information as of 9/22!2011 <br /> Record:electron Criteria: Facility ID FA0000142 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> Er4a OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0005135 New Owner ID <br /> Owner Name POLHEMUS JR, PAUL <br /> Owner DBA CENTRAL VALLEY SEWER&SEPTIC <br /> Owner Address 7000 E HARNEY LN <br /> LODI, CA 95240 <br /> Home Phone 209-745-3827 <br /> Work/Business Phone 209-369-5027 <br /> Mailing Address 7000 E HARNEY LN <br /> LODI, CA 95240 <br /> Care of POLHEMUS JR, PAUL <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0000142 <br /> Facility Name CENTRAL VALLEY SEWER& SEPTIC <br /> Location 22666 MAY RD <br /> ACAMPO, CA 95220 <br /> Phone 209-369-5027 <br /> Mailing Address 7000 E HARNEY LN <br /> LODI, CA 95240 <br /> Care of PAUL POLHEMUS, JR <br /> Location Code 99 - UNINCORPORATED A Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 00316012 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name CENTRAL VALLEY SEWER SEPTIC <br /> Title <br /> Day Phone 209-369-5027 <br /> Night Phone 209-745-3827 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0008298 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name CENTRAL VALLEY SEWER& SEPTIC (Circle One) <br /> Account Balance as of 9/22/2011: $0.00 <br /> (Circle ne) <br /> Transfer to Alive n <br /> /Elactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Dele <br /> 4244-PUMPER TRUCK PR0420025 EE0005366-LISA MEDINA Active Y N AD <br /> 4246-PUMPER YARD PRO505016 EE0005366-LISA MEDINA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned caner.operator or agent of same,acknowledge that all site,and/or project speck,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party identified as Lire OWNER on this form. I also cerlHy that all operations will be performed in accordance with all applicable Ordin ice Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S 51 URE: Date �U / S / 7 <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 b <br /> RENS: Date / / Account out: -ate D <br /> COMMENTS: <br /> DEC - 9 2011 <br /> ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <br /> \\eh-env\envision\reports\5021.rpt <br />