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Date run 12/16/2008 12:01:14F SAN JOWIN COUNTY ENVIRONMENTAL HEA H DEPARTMENT Report#5021 <br /> Run by <br /> gracility Information as of 12/16/ Pagel <br /> Record Selection Criteria: Facility ID FA0012534 <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 OW0012004 New Owner ID <br /> Owner Name BARREL TEN QUARTER CIRCLE LAND <br /> Owner DBA BARREL TEN QUARTER CIRCLE LAND <br /> Owner Address 6342 BYSTRUM RD <br /> CERES, CA 95307 <br /> Home Phone 209-538-3131 <br /> Work/Business Phone Not Specified <br /> Mailing Address 6342 BYSTRUM RD <br /> CERES, CA 95307 <br /> Care of JOHN FRANZIA, JR <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012534 <br /> Facility Name BARREL TEN QUARTER CIRCLE LAND CO <br /> Location 21801 HWY 120 <br /> ESCALON, CA 95320 <br /> Phone 209-838-3575 <br /> Mailing Address 21801 HWY 120 <br /> ESCALON, CA 95320 <br /> Care of <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 005- ORNELLAS, LEROY Fax <br /> APN 20525002 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone 209-838-3575 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0020581 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name KENNEDY/JENKSCONSULTANTS (Circle One) <br /> Account Balance as of 12/16/2008: $0.00 g t2 <br /> C5 ]�A�sc (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2965-WATER QUALITY SITE PROJECT PR0516259 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 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. \, p <br /> APPLICANT'S SIGNATURE: �e c� �C Q C" Date <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: *$372.00= Amount Paid Date / / <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: ``t Date \2— / Z G / O$ <br /> COMMENTS: <br /> \\phs-ehsql-nt\apps\envisions\reports\5021.rpt <br />