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Date run 2/21/2013 9:21:57A6 SAN JO 11N COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by voi Facility Information as of 2121/2013 <br /> Record Selection Criteria. Facility ID FA0016694 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN I Fed Tax ID <br /> Owner ID OW0013535 New Owner ID <br /> Owner Name TONY BERCHTOLD <br /> Owner DBA TONY BERCHTOLD <br /> Owner Address 8422 S MCKINLEY <br /> FRENCH CAMP, CA 95231 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 8422 S MCKINLEY <br /> FRENCH CAMP, CA 95231 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0016694 <br /> Facility Name TONY BERCHTOLD <br /> Location 8422 S MCKINLFY <br /> FRENCH CAMP, CA 95231 <br /> Phone 209_982-4167 x0 <br /> Mailing Address 8422 S MCKINLEY <br /> FRENCH CAMP, CA 95231 <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 0{31 -VILLAPUDUA Fax <br /> APN 19314004 EMaiI: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0029576 r New Account ID: <br /> Mail Invoices to Owner ' Mail Invoices to: Owner I Facility 1 Account <br /> Account Name TONY BE Piz z� (circle one) <br /> Account Balance as of 2/21/201 $53.00 -� l1 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Pr anJElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-)HIM-Farm Operations PR0524879 Active Y N A t D <br /> ELECTRONIC REPORTING STATE SURCH,PR0532686 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I.the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form I also certify that alt operations will be performed in accordance with all applicable Ordinance Codes andfor Standards and State ands <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 I <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date 1 ! <br /> Water System to be TRANSFERED: Amount Paid D to 1 1 <br /> Payment Type Check Number Recei <br /> RENS: p Date 1_�i Ll Account out: j Date / 1 1 ^ L <br /> COMMENTS: ' f 6C+/ <br /> ( �, n 416, lU! <br />