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Date am 1/10/2014 3:42:30PR SAN JO.,.IN COUNTY ENVIRONMENTAL HEAL...DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 1/10/2014 <br /> Record Selection Criteria: Facility ID FA0000151 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0000128 New Owner ID <br /> Owner Name Ensher, Alexander Barsoom, Inc. <br /> Owner DBA ENSHER, ALEXANDER & BARSOOM <br /> Owner Address 530 BERCUT DR STE D <br /> SACRAMENTO, CA 958140101 <br /> Home Phone 916-443-6875 <br /> Work/Business Phone 916-417-8205 <br /> Mailing Address PO Box 1044 <br /> Walnut Grove, CA 95690 <br /> Care of ENSHER,ALEXANDER& BARSOOM <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0000151 10461103 <br /> Facility Name Stockton Ranc W� <br /> Location 14125 earlifElmid 4 <br /> Stockton, CA 95206 <br /> Phone 916-417-8205 x <br /> Mailing Address PO Box 1044 <br /> Walnut Grove, CA 95690 <br /> Care of Jim Barsoom <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 003 - BESTOLARIDES Fax <br /> APN 12920012 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> AccountlD AR0000150 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name Stockton Ranch (Circle one) <br /> Account Balance as of 1/10/2014: $0.00 <br /> (Circle One) <br /> Transfer to ActivellnacNe <br /> ProgramlElemenl and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 19 HM-Farm Operations ✓ PRO538329 Active Y N A I D <br /> M HW GEN<5 TONS/YR PR0538328 EE0001421 -STACY RIVERA Active Y N A I D <br /> W55,EMPLOYEE HOUSING-SEASONAL<180 DAYS PR0270095 EE0002089-OMRAN SOOD Inactive Y N A I D <br /> ,28311)AST FAC >/=1,320-<10 K GAL CUMULATIVE PRO538330 EE0001421 -STACY RIVERA Active Y N A I D <br /> X834-TNC WATER SYSTEM(ORTLY) WA0461355 EE0005838-ADRIENNE ELLSAESSER Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andior 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 codify that all operations will be Performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date I / <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 ReceiveldX <br /> REHS: 1./ j Date / t o /� Account out: �"' Date <br /> COMMENTS:VC.J f G (� / ✓ <br /> 5g , 2220 , � 2831 vtA <br /> gjWL e -J <br />