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Date run 4/3/2014 1:13.57PM SAN JO.+ N COUNTY ENVIRONMENTAL HEAL )EPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 4/3/2014 <br /> Record Selection Criteria: Facility ID FA0002805 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE (date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN/Fed Tax ID <br /> Owner ID OW0002106 New, ner ID <br /> Owner Name , ,TES <br /> Owner DBA Ea tE_�zpn <br /> Owner Address 1 EL-E—Y-RD �� C <br /> Home Phone <br /> Work/Business Phone Not Specified <br /> Mailing Address +6-gQ-}{t}O AEtEY—Rq <br /> �AT-0;SA-94�47 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0002805 <br /> Facility Name #9 r — L 1 b <br /> Location 5J-25-S-J<AiSER_RD- <br /> &TE)eKTON-,�CA 9521 G:_ <br /> Phone 44_R.SCt&&D52 <br /> Mailing Address te8f"ND �_(D_A_D <br /> NQV-AT0-C—A­9494-' <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 18104006 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name U -gAfi}K-t}R-_fleNAL- S&NT-R <br /> Title VY <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002366 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name 42E-AREE7JEFF­-H-39=-40 (Circle One) <br /> Account Balance as of 4/3/2014: $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 /> 2765-EMPLOYEE HOUSING-PERMANENT>180 DAYS PR0270040 EE0008987-SCOTT SANGALANG Active Y N A I D <br /> 4630-NTNC WATER SYSTEM WA0461354 EE0005838-ADRIENNE ELLSAESSER Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENTS I,the undersigned owner, ralor or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form I also rti that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or <br /> Federal Laws. .�J. <br /> L <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: ✓ylit Date / _/ Account out: Date <br /> COMMENTS: <br />