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Date run 11/1g/2004 2:22:24P SANJO�COUNTYENVIRONMENTALREAT&DEPARTMENT <br /> Run by Facility Information as of 11/18/20 Repo #5021 <br /> Pagel <br /> Record Selection Crib, la'. Facility ID FA0015787 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner I OW0003421 New Owner ID <br /> Owner Name CHINCHIOLO, ROBERT <br /> Owner DBA SIERRA HILLS PACKING INC <br /> Owr'er Address PO BOX 55096 <br /> STOCKTON, CA 95215 <br /> Home Phone 209-931-5157 <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 55096 <br /> STOCKTON, CA 952159144 <br /> Care of CHINCHIOLO STEMILT CALIF, LLC <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0015787 <br /> Facility Name SIERRA HILLS PACKING <br /> Location 4505 4799 N JACK TONE RD <br /> STOCKTON, CA 95215 <br /> Phone 209-931-5157 <br /> Mailing Address PO BOX 55096 <br /> STOCKTON, CA 95205 <br /> Care of CHINCHIOLO STEMILT CALIF, LLC <br /> Location Code 99- UNINCORPORATED AREA APN:08917052 <br /> BOS District 004-SEIGLOCK, JACK SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0027366 NewAccount ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name NEIL O ANDERSON &ASSOC INC (Circle One) <br /> Account Balance as of 11/18/2004: $0.00 <br /> Transfer to (Circle One) <br /> Active/Inacwe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2965-H2O QUAL SITE PROJECT PR0523363 EE0000684-MICHAEL INFURNA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,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 TRANSFERED: •$20.00= Amount Paid Date / / <br /> Water System to be TRANSFERED: "$155.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date / / <br /> COMMENTS: <br /> \\phs-ehsgl-nt\apps\envisions\reports\5021.rpt <br />