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Date run 2/11/2010 2:57:47PN SAN JC 'JIN COUNTY ENVIRONMENTAL HEA 1-1EPARTMENT Report#5021 <br /> Run+by 1�73' Pagel <br /> Facility Information as of 2/11/201U <br /> Record Selection Criteria: Facility ID FA0016805 <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 OW0013646 New Owner ID : <br /> Owner Name Q-UA11_CRE K VINEYARDS -DC 45y—tt;I2;zX, L W <br /> Owner DBA QUAIL CREEK VINEYARDS IZ V I - <br /> Owner Address .2 004--E-44WY4--- #,& <br /> TOGKTOWCA--95215 cJ", �'.� 257q-0 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address p4)-gQX-588_ 134 b L i n n QoctJ <br /> WOODBRIDGE, CA 95258 LQd CA x5240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0016805 <br /> Facility Name Q4 tnu �o��K VINEYARDS <br /> Location 21001 E HWY 4 <br /> STOCKTON, CA 95215 _ <br /> Phone -x0--_ Z 0 q -I---5-7- <br /> Mailing Address 3 L " n /&eL J <br /> -WOOBBRtDGE, CA-95258 / hca(i , C 1'S Z9�0 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 004-VOGEL, KEN Fax ZS Cf - Z <br /> APN EMail: 1, }f r:�QS CoO d jefe itl<,- (041 <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION O j r, p <br /> Contact Name /`6ki' rr e 1 o Ar) r V4Nfe <br /> Title <br /> Day Phone ZD4' -32 - 2-3Z I!-298 Q-8 "36 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0029687 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name QUA+E-CREEK VINEYARDS LI)C (z�u r / ( (Circle One) <br /> Account Balance as of 2/11/2010: $262.00 1 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0529699 EE0009488-JEFFREY WONG Active Y N A I D <br /> 2223-AGRICULTURAL HAZ MAT STORAGE FACILPRO524990 Inactive Y N A I D <br /> J2836--AST FAC -SPCC EXEMPT PR0529698 EE0009488-JEFFREY WONG Active,Exempt Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PRO532222 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 TRAN'SFERED: *$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: *$372.00= Amount Paid Date <br /> Payment Type heck Number Receiv <br /> REHS: a Date_0Z / I. Z / Account out: Date A- <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />