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Datep!n 6/5/2009 1:47:31PM SAN JOAON COUNTY ENVIRONMENTAL HEAL EPARTMENT Report#5021 <br /> Run by I - Paget <br /> A Facility Information as of 8/5/2009 <br /> Record Selection Criteria: Facility ID FA0017131 <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 OW0013972 New Owner ID : <br /> Owner Name y 5°*r'r-//r Y 77 tags <br /> Owner DBA Y .0 Fe AIS / <br /> Owner Address S 3(LS. lullSLS A&W <br /> LDA ) n e/ cts <br /> Home Phone Not Specified � <br /> Work/Business Phone Not Specified C&C,7) -3 <br /> Mailing Address 20101 STATE HIGHWAY 12 <br /> ISLETON, CA 95641 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017131 <br /> Facility Name Y L.ER's <br /> Location 20101 STATE ROUTE 12 <br /> ISLETON, CA 956Fi11 <br /> Phone�g48 7�Tgpefl x0(20 9) 3 3 <br /> Mailing Address a2e+04-'Torr r cj rt nv G hU4 <br /> 1 Lop j a c rR L9.C6:Lj %,- <br /> Care of �— <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 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 AR0030013 f/ New Account ID: <br /> Mail Invoices to Owner /%/'7 Mail Invoices to: Owner / Facility / Account <br /> Account Name (Circle One) <br /> Account Balance as of 8/5/2009: $0.00 <br /> (Circle One) <br /> Transferto Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2223-AGRICULTURAL HAZ MAT STORAGE FACILPRO525316 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,PHS/EHD 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 Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date—/-1 <br /> Water System to be TRANSFERED: "$372.00= Amount Paid DatPayme <br /> REHS:nt Type 0=_ Gtleck Number Date /�/ � Account out: Receiv Date /� L- <br /> COMMENTS' <br /> V <br /> ia'i-,� �3D ® K tz> <br /> \\eh-env\envision\reports\5021.rpt <br />