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Date run 12/7/2004 8:51:23AN SA Report#5021 <br /> f, �QUIN COUNTY ENVIRONMENTAL TH DEPARTMENT <br /> Run by., Pagel <br /> Facility Information as of 12/7/2004 <br /> Record Selection Criteria: Facility ID FA0004385 <br /> Make changes/corrections in RED ink or pencil. <br /> "Is— INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0003300 New Owner ID <br /> Owner Name JESSOP, LOREN <br /> Owner DBA SIERRA ORGANICS <br /> Owner Address 1480 HERITAGE TRAIL <br /> CARMARILLO, CA 93012 <br /> Home Phone 209-591-9658 <br /> Work/Business Phone 209-982-4936 <br /> Mailing Address PO BOX 31750 <br /> STOCKTON, CA 95213 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0004385 <br /> Facility Name SIERRA ORGANICS <br /> Location 4343 S MCKINLEY AVE <br /> STOCKTON, CA 95206 <br /> Phone 209-982-4936 <br /> Mailing Address PO BOX 31750 <br /> STOCKTON, CA 95213 <br /> Care of LOREN JESSOP <br /> Location Code 99- UNINCORPORATED AREA APN:STOCK43 <br /> BOS District 001 - GUTIERREZ, STEVE SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0004067 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name SIERRA ORGANICS (Circle One) <br /> Account Balance as of 12/7/2004: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2244-PACT TRANSFER RECORD-OES PR0522284 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 4633-TNC WATER SYSTEM WA0461187 EE0000753-WILLIE NG 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: *$155.00= Amount Paid Date <br /> Payment Type Check Number Received b/ <br /> REHS: Date / / Account out: _ Date / 1-7 <br /> COMMENTS: <br /> �f �3 5 0 l.c t.�1✓�Sz"�- C� -P�s i s� �c <br /> 6 :�—'W✓ f 313 6 q u4--N71 <br /> \\phs-ehsq 1-nt\apps\envision s\reports\5021.rpt <br />