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ER1d <br /> 2/10/2015 2:11:58PA SAN JO�J18 COUNTY ENVIRONMENTAL HEAD DEPARTMENT P <br /> Report Y5021 <br /> Facility Information as of 2/10/2015 Pagel <br /> election Criteria: Fact ID FA0016: <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 <br /> SSN/Fed Tax ID <br /> Owner ID OW0013782 - New Owner ID <br /> Owner Name ENSHER ALEXANDER BARSOOM INC <br /> Owner DBA ENSHER ALEXANDER BARSOOM INC <br /> Owner Address 0 UPPER JONES TRACT(CAMP 2 <br /> HOLT, CA 95234 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 27 <br /> HOLT, CA 95234 <br /> Care of <br /> FACILITY FILE INFORMATION 10 Ctfs, ti-03 <br /> Facility lD/CERS ID FA0016941 -+&MS657 <br /> Facility Name ENSHER ALEXANDER BARSOOM INC <br /> Location 0 UPPER JONES TRACT(CAMP 2 <br /> HOLT, CA 95234 <br /> Phone 916-417-5269 x0 <br /> Mailing Address PO BOX 27 <br /> HOLT, CA 95234 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 12920012 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 AR0029823 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name ENSHER ALEXANDER BhRSOOM INC (Circle One) <br /> Account Balance as of 2/10/2015: $107.00 f <br /> 2 Z F*Q00O1/ (Circle One) <br /> :/1 R D .3 Q' p JJI��' Transfer to AcOve/Inactve <br /> Prog MEfement and Desctl tido " S r+ Record ID Employee ID and Name Status Nev OwneO Delete <br /> 1958-HM-Farm Operations PRO525126 Active Y N A I D <br /> 2221 -USED OIL ONLY-<5 TONS/YR PRO538591 Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532807 Inactivt Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS/EHD hourly charges associated with Nis facility <br /> or activity will be billed to the party identified as Ne OWNER on this form. I also certify that aft operations will be performed in accordance with all applicable Ordinance Codes andof Standards and State andor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date_/ I <br /> Payment Type Check Number Receivgd by <br /> REHS: Date Z / U / t Account oDate <br /> COMMENTS', <br /> ao0 <br />