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Date run 1/16/2007 9:18:37AN SAN JO IN COUNTY ENVIRONMENTAL HEAN DEPARTMENT Report#5021 <br /> Pagel <br /> Run by <br /> Facility Information as of 1/16/2007 <br /> Record Selection Criteria: Facility ID FA0012534 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANG€(� <br /> OWNER FILE INFORMATION <br /> Owner ID OW00 4180 New Owner ID d� �''t'O� <br /> Owner Name �� IT C�.Jcti�(tvCrt-�l-� um o- <br /> Owner DBA <br /> 5 <br /> Owner Address `��� KfrN"^ IZeL <br /> Genes CA <br /> Home Phone Not ec ied <br /> Work/Business Phone AoJ -5 3 9 -3 19 <br /> Mailing Address 2 01 E H 120 <br /> E CALON, A 95320 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility FA001253 <br /> Facility Nam ►rCtv>Cfe t ►A Mel er, <br /> Location 21801 HWY 120 <br /> ESCALON, CA 95320 <br /> Phone 209-838-3575 <br /> Mailing Address 21801 HWY\MN E-G49 [2-0 <br /> ESCALON, CA 95320 <br /> Care of <br /> Location Code 99 - UNINCORPORATED AREA APN:20525002 <br /> BOS District 005 -ORNELLAS, LEROY SIC Code: <br /> ACCOUNTS RECEIVABLE FI A7N <br /> Accoun ID AR002058% New Account ID: <br /> Mail Invoices Mail Invoices to: Owner / Facility / Account <br /> Account Name KGNKG-J��SGKk-S (Circle One) <br /> Account Balance as of 1/16/2007: $0.00 6Z IFols,t" S!- <br /> SQK�►'CASCO 9 t{107- (Circle One) <br /> Transfer to Active/Inactve <br /> New Owner? Delete <br /> Program/Element and Description Record ID Employee ID and Name Status <br /> 2 PR0516259 EE0006219-LORI DUNCAN Active Y N A I D <br /> ;L c%S <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. <br /> APPLICANT'S SIGNATURE: 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 1 10 Received by <br /> REHS: Date / / Account out: Date 0 <br /> COMMENTS: <br /> (o <br /> \\phs-ehsgl-nt\apps\envisions\reports\5021.rpt <br />