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Date run 1/3112013 2:21:58PN SAN J(`i COUNTY ENVIRONMENTAL,HEA *,,#4 DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Informatson as of 1/31/2013 <br /> Record Selection Criteria: Facility ID FA0016955 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN1 Fed Tax ID <br /> Owner ID OW0013796 New Owner ID <br /> Owner Name SKS ENT _ <br /> Owner DBA SKS ENT <br /> Owner Address 18832 MELLO AVE <br /> RIPON, CA 95366 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 1300 <br /> LOCKEFORD, CA 952371300 <br /> Gare of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0016955 <br /> Facility Name SKS ENT <br /> Location 18832 MELLO AVE <br /> RIPON, CA 95366 <br /> Phone 209-983-0642 x0 <br /> Mailing Address PO BOX 1300 <br /> LOCKEFORD, CA 952371300 <br /> Care of <br /> Location Code 99 - UNINCORPORATED A Alt Phone <br /> BOS District 005 - ORNELLAS, LEROY Fax <br /> All 24513017 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0029837 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner ! Facility 1 Account <br /> Account Name SKS ENT (Circle One) <br /> Account Balance as of 113112013: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> ProgranVElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> HM-Farm Operations PR0525140 Active Y N A i D <br /> 222 SM HW GEN <5 TONSl1 R PR0528931 EE0002670-MUNIAPPA NAIDU Active Y N A I Q <br /> 40-AST EXEMPT FAC < 1,320 GAL PR0528930 EE0002670-MUNIAPPA NAIDU Active,Exempt Y N A - D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0531565 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT, I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor 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 all operations will be performed in accordance with all applicable Ordinance Codes andror Standards and State and+or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date ! 1 <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Ri by <br /> RENS: Date__1371 1 1 Account out: l j j Date�i_�1� <br /> COMMENTS: <br />