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Date mn 3/18/2015 4:14:22Ph SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/18/2015 <br /> Record Selection Criteria: Facility ID FA0004500 <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: 1 SSN/Fed Tax ID : <br /> Owner ID OW0003415 New Owner ID <br /> Owner Name Valley Crest Companies <br /> Owner DBA VALLEY CREST TREE COMPANY <br /> Owner Address 28915 FUNCK RD <br /> FARMINGTON, CA 95230 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-886-5511 <br /> Mailing Address 28915 FUNCK RD <br /> FARMINGTON, CA 95230 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0004500 10181639 <br /> Facility Name VALLEY CREST TREE COMPANY <br /> Location 28915 FUNCK RD <br /> FARMINGTON, CA 95230 <br /> Phone 209-886-5511 x <br /> Mailing Address-2$9}5+ -Rg l-�>C> <br /> FARMINGTON, CA 95230 <br /> Care of Emory Chow <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004-WINN, CHARLES Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0004182 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name VALLEY CREST TREE COMPANY (Clrae One) <br /> Account Balance as of 3/18/2015: $292.00 <br /> (Circle One) <br /> Transfer to Active/Inactme <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PRO525793 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO530613 EE0009488-JEFFREY WONG Active Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PRO530612 EE0009488-JEFFREY WONG Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0635383 EE0009000-HARPRIT MATTU Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO534157 Inactive Y N A I D <br /> 4630-NTNC WATER SYSTEM WAG461343 EE0005838-ADRIENNE ELLSAESSER Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ander project specific,PHS/EHD hourly charges a itiMlead with this faulily <br /> or activity will be billed to the party identified as the OWNER on this form. I also cenlfy that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> 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: Date / / Account out: �izz>— Date a_/—k <br /> COMMENTS: <br /> M" i (e�ur ✓� / Cho �ceee4fl-ele / use �o3ox ��f nr� <br />