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Datetun 6/17/2008 11:14:51AI SAN J0jVIN COUNTY ENVIRONMENTAL HEA#H DEPARTMENT Repcd#5021 <br /> Pagel <br /> Run by 'f. <br /> Facility Information as of 6/1712 <br /> Record Selection Criteria: Facility ID FA0008093 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW 0006691 New Owner ID <br /> owner Name CONTINENTAL GRAIN COMPANY <br /> Owner DBA <br /> owner Address 222 S RIVERSIDE 1100 <br /> CHICAGO, IL 60606 <br /> Home Phone Not Specified --- <br /> Work/Business Phone <br /> Mailing Address 222 S RIVERSIDE STE 1100 <br /> CHICAGO, IL 60606 <br /> Care of P-gRQVAtN-- T/AvA -s 't-AT rl <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0008093 <br /> Facility Name CONTINENTAL GRAIN CO <br /> Location 9504 S HARLAN RD <br /> FRENCH CAMP, CA 95231 <br /> Phone 209-982-1121 C7 N) e' 4 AMl:�7Q <br /> XMailing Address 222 S RIVERSIDE 20 t! IL- fZA,-J >6f- ��}CL^ <br /> CHICAGO, IL 60606 _�INrAf,o t,L fao�- <br /> Care of MBROWN <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 001 -GUTIERREZ, STEVE Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name 8R6VO4-, M— JPmqp�s tA`(Lo yt <br /> Title <br /> Day Phone 312-287-54 g() jg 1 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0015386 NewAccount ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name CONTINENTAL GRAIN COMPANY (Circle One) <br /> Account Balance as of 6/17/2008: $735.00 <br /> (Cimle One) <br /> Transfer to ActiveMaclve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2960-RWQCB SITE PR0508462 EE0006219-LORI DUNCAN 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 speck,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the parry identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinate Codes and/or Standards and <br /> State andlor Federal Laws. r�, \\ \ 2 -0s <br /> c <br /> APPLICANT'S SIGNATURE: rmQ-¢- CA' JI„ ` p'&A Date �0 1 J / -0 O <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: —*$372.00= Amount Paid Date <br /> Payment Type Check Number ReWive y <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\phs-ehsgl-nt\apps\envisions\reports\5021.rpt <br />