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Date run 1/24/2011 11:03:44AI SAN JOA—IJIN COUNTY ENVIRONMENTAL HEAI Tr-I DEPARTMENT p <br /> Run by 5290 Report#5021 <br /> "3 <br /> Facility Information as of 1/24/20'T� Pagel <br /> Record Selection Criteria: Facility ID FA0017466 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> SSN/Fed Tax ID <br /> Owner ID OW0014307 New Owner ID <br /> Owner Name DAVID LAM <br /> Owner DBA DAVID LAM <br /> Owner Address 22888 E HWY 120 <br /> ESCALON, CA 95320 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 22888 E HWY 120 <br /> ESCALON, CA 95320 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017466 _4901-b" LA-M <br /> Facility Name DAVID LAM <br /> Location 22888 E HWY 120 <br /> ESCALON, CA 95320 <br /> Phone 209-838-0788 x0 <br /> Mailing Address 22888 E HWY 120 <br /> ESCALON, CA 95320 <br /> Care of <br /> Location Code 99 - UNINCORPORATED A Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 24702004 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 AR0030348 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility I Account <br /> Account Name DAVID LAM (Circle One) <br /> Account Balance as of 112412011: $0.00 <br /> (Circle One) <br /> Transferto Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner'? Delete <br /> 2223-AGRICULTURAL HAZ MAT STORAGE FACILPRO525651 Active Y N A I D <br /> \2840-AST EXEMPT FAC <1,320 GAL PR0529608 EE0000753-WILLY NG Active,Exempt Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PRO532982 Active 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,PHSlEHD hourly charges associated with this <br /> facility 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 Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S 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 Recei ey diy <br /> REHS: Date 1 1 Account out: t�� Date Z'( ! l l <br /> COMMENTS: <br /> Ileh-envlenvisionlreports15021.rpt <br />