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Date run 7/26/2004 10:16:51AI SAN JUIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/26/2 c�i <br /> Record Selection Criteria: Facility ID FA0010399 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <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 FA0010399 <br /> Facility Name BARREL TEN QUARTER CIRCLE - ESCALO <br /> Location 21801 HWY 120 <br /> ESCALON, CA 95320 <br /> Phone 209-571-4100 <br /> Mailing Address 6342 BYSTRUM RD <br /> CERES, CA 95307 <br /> Care of JOHN FRANZIA, JR <br /> Location Code 99 - UNINCORPORATED AREA APN:205-250-02 <br /> BOS District 005-ORNELLAS, LEROY SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017399 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name BARREL TEN QUARTER CIRCLE- ESCALON (Circle One) <br /> Account Balance as of 7/26/2004: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> New Owner? Delete <br /> Program/Element and Description Record ID Employee ID and Name Status <br /> 2212-HAZ WASTE CA FAC STATE SERVICE FEE PR0506989 EE0007289-ALISON YOUNGBLOOD Inactive Y N A I D <br /> 2214-CalARP FAC STATE SURCHARGE FEE PR0518939 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO514310 EE0008317-RAYMOND VON FLUE Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0512687 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2226-CaIARP PROGRAM PR0514775 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2232-HAZARDOUS WASTE CA FACILITY PR0506988 EE0007289-ALISON YOUNGBLOOD Inactive Y N A I D <br /> 2232-HAZARDOUS WASTE CA FACILITY PR0507119 EE0007289-ALISON YOUNGBLOOD Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0520293 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0522035 Active Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84) PR0502109 EE0007289-ALISON YOUNGBLOOD Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPR0506990 EE0007289-ALISON YOUNGBLOOD Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPR0510399 EE0000000-HAZ MAT SJC OES Inactive 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. <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-ehsq I-nt\apps\Envisions\Reports\5021.rpt <br />