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Date run 2/25/2014 12:13:58PI SAN JC JIN COUN rY ENVIRONMENTAL HEA DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 2/25/2014 <br />Record Selection Criteria: Facility ID FA0003410 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0002534 Case Number: 016193 <br />Owner Name <br />VAN EGMOND,GERARD IRV TRST1997 <br />Owner DBA <br />VAN EGMOND, G C (GREENDALE) <br />Owner Address <br />8220- E LIBERTY RD <br />Pr ram/Element and Description <br />GALT, CA 95632 <br />Home Phone <br />209-712-7482 <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />PO BOX 580 <br />- GRADE A DAIRY <br />22 - SM HW GEN <5 TONS/YR <br />GALT, CA 95632 <br />Care of <br />GERARD VAN EGMOND IRV TRST1997 <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0003410 10,181,143 <br />Facility Name VAN EGMOND, G C (GREENDALE) <br />Location 8220 E LIBERTY RD <br />GALT, CA 95632 <br />Phone 209-712-7482 <br />Mailing Address PO BOX 580 <br />GALT, CA 95632 <br />Care of GERARD VAN EGMOND IRV TRST1997 <br />Location Code 99 - UNINCORPORATED,8 <br />Bos District 004 - VOGEL, KEN <br />APN 00703027 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name VAN EGMOND, GERARD C <br />Title <br />Day Phone 209-334-9118 <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <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 />Alt Phone <br />Fax <br />EMail : <br />Account ID AR0002987 New Account ID <br />Mail Invoices to Facility GV P A <br />Account Name VANE M6N , C (GREENDALE) <br />Account Balance as of 2/25/201 • $.266:0 a <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transferto <br />Active/Inactve <br />Pr ram/Element and Description <br />Record ID Employee ID and Name <br />Status New Owner? <br />Delete <br />1958 HM -Farm Operations <br />PR0525946 <br />Active Y N <br />A G D <br />- GRADE A DAIRY <br />22 - SM HW GEN <5 TONS/YR <br />PR0200140 EE0004589 - KADEANNE LINHARES <br />PR0530459 EE0001422 - ARIS CACAPIT <br />Inactive Y N <br />Active Y N <br />AD <br />A I Dj <br />g 30 AST FAC - SPCC EXEMPT <br />PR0530458 EE0001422 - ARIS CACAPIT <br />Active,! Y N <br />A -15 <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PRO531862 <br />Inactive Y N <br />AD <br />4620 - DAIRY - WATER SUPPLY <br />WA0515671 EE0004589 - KADEANNE LINHARES <br />Active Y N <br />A I !. <br />� <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andror 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 andror Standards and State andror <br />Federal Laws. <br />', Date <br />APPLICANT'S SIGNATURE: Y\ c7 1 .,�'l �E', <br />Ic"r �- .'-/ �. - ,- <br />Program Records to be TRANSFERED: <br />' $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: <br />Amount Paid Date <br />Payment Type U C` Number <br />fC � <br />Date /22/ I Account out: Rece'v by <br />Date l l <br />REHS: <br />