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4 <br /> 1 <br /> Date run 2/10/2015 2:11:58PN SAN JC UIN COUNTY ENVIRONMENTAL HEA I DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/10/2015 <br /> Record Selection Criteria: Facility ID FA0016941 <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 OW0013782 New Owner ID <br /> Owner Name ENSHER ALEXANDER BARSOOM INC <br /> Owner DBA ENSHER ALEXANDER BARSOOM INC <br /> Owner Address 0 UPPER JONES TRACT (CAMP 2 <br /> HOLT, CA 95234 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 27 <br /> HOLT, CA 95234 <br /> Care of <br /> FACILITY FILE INFORMATION 10Q(a (to-3 <br /> Facility ID/CERS ID FA0016941 X657 <br /> Facility Name ENSHER ALEXANDER BARSOOM INC <br /> Location 0 UPPER JONES TRACT (CAMP 2 <br /> HOLT, CA 95234 <br /> Phone 916-417-5269 x0 <br /> Mailing Address PO BOX 27 <br /> HOLT, CA 95234 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District 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 /> Account ID AR0029823 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name ENSHER ALEXANDER BARSOOM INC (Circle One) <br /> Account Balance as of 2/10/2015: $107.00 -f— �v�/ <br /> 2 ,/a m Y,Jl ODO�/S/ (Circle One) <br /> pQ S(�2 O c J l� f T! Transferto Active tete ve <br /> Pro mlElement and Descri tio(nl c��7J Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PR0525126 Active Y N A I D <br /> 2221 -USED OIL ONLY-<5 TONS/YR PR0538591 Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532807 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or 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 performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or <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 Receiv/�dlf��y <br /> REHS: Date 2 / �� / t Account out: 7z Date /X-- <br /> COMMENTS: <br /> X _COMMENTS: <br />