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Date run 3/15/2016 8:19:39AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report #5021 <br />Run by - Pagel <br />Facility Information as of 3/15/2016 <br />Record Selection Criteria: Facility I D FA0016730 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0013571 <br />Owner Name <br />NORMAN KNOLL <br />Owner DBA <br />NORMAN KNOLL <br />Owner Address <br />21421 WARD RD <br />Phone <br />ACAMPO, CA 95220 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-334-2122 <br />Mailing Address <br />7068 S MADISON WAY <br />Location Code <br />CENTENNIAL, CO 80122-1856 <br />Care of <br />Fax <br />FACILITY FILE INFORMATION <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />1 SSN/Fed Tax ID <br />New Owner ID : <br />Facility ID / CERS ID <br />FA0016730 10185311 <br />Facility Name <br />NORMAN KNOLL <br />Location <br />21421 WARD RD <br />ACAMPO, CA 95220 ` <br />Phone <br />209-334-2122 x ' <br />Mailing Address <br />7068 S MADISON WAY <br />CENTENNIAL, CO 80122-1856 <br />Care of <br />Norman Knoll <br />Location Code <br />Alt Phone <br />BOS District <br />Fax <br />APN <br />01726011 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 AR0029612 <br />Mail Invoices to Account Mail Invoices to <br />Account Name Jonathan Brown <br />Account Balance as of 3/15/2016: $266.00 <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner?fete <br />1958 - HM -Farm Operations PR0524915 EE0002670 - MUNIAPPA NAIDU Active Y N A D <br />2220 - SM HW GEN <5 TONS/YR PR0530203 EE0001422 - ARIS VELOSO Active Y N A D <br />2830 - AST FAC - SPCC EXEMPT PR0530143 EE0001422 - ARIS VELOSO Inactive Y N A D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0531750 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: l"QC) TyL�CG`�a et <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />EHD Staff: <br />COMMENTS <br />" $25.00 = Amount Paid Date / ! <br />Amount Paid Date <br />Date 3 / /5- / / <br />�IG+�S c.� Gw✓� � G+-� <br />Receivedy <br />Account out: Date / 5 / <br />Invoice #: <br />