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Date run 2/18/2016 2:32:34Ph SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 2/18/2016 <br />Record Selection Criteria: Facility ID 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 />ACAMPO, CA 95220 <br />ACAMPO, CA 95220 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-334-2122 <br />Mailing Address <br />214zn --YVAREI�-RD <br />Norman Knoll <br />20 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0016730 <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 />21 21 ^r,-TrnRDARD <br />A 22C <br />Care of <br />Norman Knoll <br />Location Code <br />Account Balance as of 2/18/2016: $266.00 <br />BOS District <br />APN <br />01726011 <br />10185311 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN/Fed Tax ID <br />New Owner ID : <br />EMERGENCY NOTIFICATION CONTACT INFORMATION / <br />Contact Name <br />Title r <br />Day Phone ✓ <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Alt Phone <br />Fax <br />EMail : <br />Account ID AR0029612 <br />New Account ID: <br />: <br />Mail Invoices to Account <br />Mail Invoices to: <br />Owner / <br />Facility / <br />Account <br />Account Name Jonathan Brown <br />(Circle One) <br />Account Balance as of 2/18/2016: $266.00 <br />(Circle One) <br />Transfer to <br />Active/Inactve <br />Program/Element and Description <br />Record ID <br />Employee ID and Name <br />Status <br />New Owner? <br />Delete <br />1958 - HM -Farm Operations <br />PR0524915 <br />EE0002670 - MUNIAPPA NAIDU <br />Active <br />Y N <br />A I D <br />2220 - SM HW GEN <5 TONS/YR <br />PR0530203 <br />EE0001422 - ARIS VELOSO <br />Active <br />Y N <br />A I D <br />2830 - AST FAC - SPCC EXEMPT <br />PR0530143 <br />EE0001422 - ARIS VELOSO <br />Inactive <br />Y N <br />A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG <br />PR0531750 <br />Inactive <br />Y N <br />A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT. I, the undersigned owner, operator or agent <br />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 <br />will be performed in accordance with all applicable Ordinance Codes and/or Standards <br />and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: Date <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 = <br />Date <br />Amount Paid Date -/-/ <br />_ Amount Paid Date <br />Received by <br />Account out: Date �_! Z //(0' <br />Invoice #: <br />��l`��\1�1 ,�o�rJIPCSS GV\G�l�±Q2 �tP7 <br />vf,tJ V <br />per ���A <br />\ <br />