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Date run 61/3/2010 8:33:35AM SAN JO," 1JIN COUNTY ENVIRONMENTAL HEAD"' DEPARTMENT Report#5021 <br /> Run,by Pagel <br /> Facility Information as of 8/3/201�. - <br /> Record Selection Criteria: Facility ID FA0016482 sm <br /> Make changes/corrections in RED ink. <br /> �'�" INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0008071 Case Number: H06440 New Owner ID <br /> Owner Name RIPON FARM SERVICES <br /> Owner DBA RIPON FARM SERVICE <br /> Owner Address 938 S HWY 99 E FRONTAGE RD <br /> RIPON, CA 953660806 <br /> Home Phone 209-476-8213 <br /> Work/Business Phone 209-599-2188 <br /> Mailing Address PO BOX 806 <br /> RIPON, CA 953660806 <br /> Care of OUDEN, BUD DEN <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0016482 <br /> Facility Name RIPON FARM SERVICE <br /> Location 932 S HWY 99 E FR RD <br /> RIPON, CA 95366 <br /> Phone 209-599-2188 <br /> Mailing Address PO BOX 806 <br /> RIPON, CA 95366 <br /> Care of <br /> Location Code 99- UNINCORPORATED,8 Alt Phone <br /> BOS District 005- ORNELLAS, LEROY Fax <br /> APN 26102007/11 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone 209-599-2188 0` f <br /> _ ¢ <br /> ACCOUNTS RECEIVABLE FILE INFORMATION G 3 b v `(� Y u �n e a G <br /> Account ID AR0029006 C` a`� C 'p t 1 C� _ 1 �9 New Account ID: <br /> Mail Invoices to ccount v C I 1 J Mail Invoices to: Owner / Facility / Account <br /> Account Name ON FARM SERVICE (Circe One) <br /> Account Balance as of 8/3/2010: $954.50 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2960-RWQCB SITE PR0524571 EE0001459-VICKI MCCARTNEY 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. \\ \ <br /> APPLICANT'S SIGNATURE: S Q e Q X14 eX.n,F� VSA \ `� -�`-��� �� Date A7 <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: _ Date $ / 3 <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />