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0mc run 2/10/2014 4:44:16PR SAN J( ,UIN COUNTY ENVIRONMENTAL HEA,,,,/DEPARTMENT Report#5021 <br /> Run by, Pagel <br /> Facility Information as of 2/10/2014 <br /> Record Selection Criteria: Facility ID FA0016899 <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 OW0013740 New Owner ID <br /> Owner Name GEORGE BROTHERS <br /> Owner DBA GEORGE BROTHERS <br /> Owner Address 21239 S OLIVE AVE <br /> RIPON, CA 95366 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 21239 S OLIVE AVE <br /> RIPON, CA 95366 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0016899 10,185,589 <br /> Facility Name GEORGE BROTHERS <br /> Location 21239 S OLIVE AVE <br /> RIPON, CA 95366 <br /> Phone 209-599-3579 x0 <br /> Mailing Address 21239 S OLIVE AVE <br /> RIPON, CA 95366 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 22810005 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 AR0029781 5(� NewAcocunt ID: <br /> Mail Invoices to Owner ��t 4f y V`+^ Mail Invoices to: Owner / Facility / Account <br /> Account Name GEORG THERS v0 f Z Qr v (Circle One) <br /> Account Balance as of 2/10/2014: $53.00 �CYY'J ' v <br /> (Circle One) <br /> Transferto Activelinachie <br /> P ram/Element and Description Record ID Employee ID and Name Status New Ovmer! Delete <br /> 1958 HM-Farm Operations PRO525084 Active Y N A ® D <br /> 2 0-AST EXEMPT FAC <1,320 GAL PR0530675 EE0000753-WILLY NG Active,l Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533327 Inactivr Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor 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 certify that all operations will be peRonned 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 Check Number Race <br /> REHS: T i <br /> Y <br /> Date / /I Ld Account out: Date / /� <br /> COMMENTS: 0 <br />