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Date run 2/18/2015 2:36:49PN SAN JC UIN COUNTY ENVIRONMENTAL HEA i DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 2/18/2015 <br />Record Selection Criteria: Facility ID FA0016940 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0013781 <br />Owner Name <br />RALPH ROOS <br />Owner DBA <br />RALPH ROOS <br />Owner Address <br />22742 S MANLEY RD <br />Phone <br />RIPON, CA 95366 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-599-2862 <br />Mailing Address <br />22742 S MANLEY <br />Location Code <br />RIPON, CA 95366 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0016940 10185655 <br />Facility Name <br />RALPH ROOS <br />Location <br />22742 S MANLEY RD <br />RIPON, CA 95366 <br />Phone <br />209-599-2862 x0 <br />Mailing Address <br />22742 S MANLEY <br />RIPON, CA 95366 <br />Care of <br />RALPH ROOS <br />Location Code <br />BOS District <br />APN <br />26122001 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0029822 <br />Mail Invoices to Owner <br />Account Name RALPH <br />Account Balance as of 2/18/2015: 26.00 <br />Program/Element and Description <br />Make changes/corrections in RED ink. [[�� <br />INFORMATION CHANGE (date) U <br />OWNERSHIP CHANGE (date) <br />SSN /Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />d Li�- Mail Invoices to: <br />«i <br />PS4 'S�Ljf-cvps�' <br />Record ID Employee ID and Name �v <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Status New Owner? Delete <br />HM -Farm Operations PR0525125 EE0002474 - MICHAEL PARISSI Active Y N A I D <br />2830 - ST FAC - SPCC EXEMPT PR0530281 EE0009001 - ELENA MANZO Active Y N A <�I) D <br />RSC - ELECTRONIC REPORTING STATE SURCHARG PR0534403 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 andror Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment T e heck Number Received by _ <br />REHS: . 1 %/1dJ L`--, Date Account out:1 LIb Date /-9 l 5 <br />COMMENTS: n k l - o� P V r <br />A <br />