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Daterun 6121101 3:38:17PM SAN 4QUIN COUNTY PUBLIC HEALTH SEF 'ES Report #: 6023 <br /> Run by :1.0'� Facility Information as of 6121101 *"WP� Page n: 1 <br /> Record Selection Criteria: Facility IO FA0004052 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID: OW0005570 New Owner ID <br /> Owner Name: COSTAMAGNA, ERNEST <br /> Owner DBA: FARM UGT <br /> Owner Address: PO BOX 262 <br /> BANTA, CA 95304 <br /> Home Phone: 209-481-2864 <br /> Work/Business Phone: 209-481-2864 <br /> Mailing Address: PO BOX 262 <br /> BANTA, CA 95304 <br /> Care of: ERNEST COSTAMAGNA <br /> FACILITY FILE INFORMATION <br /> Facility ID: FA0004052 <br /> Facility Name: FARM UGT <br /> Location: 18775 S TOM PAINE RD <br /> TRACY, CA 95376 <br /> Phone: 209-931-3770 <br /> Mailing Address: PO BOX 262 <br /> BANTA, CA 95304 <br /> Care of: ERNEST COSTAMAGNA <br /> Location Code: 99- UNINCORPORATED AREA APN: 213-020-30-8 <br /> BOS District: 005- BEDFORD, LYNN SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0003700 New Account ID: <br /> Mail Invoices to: Mail Invoices to: Owner/Facility/Account <br /> Account Name: COSTAMAGNA, ERNEST (Circle One) <br /> Account Balance as of 6121101: $0.00 <br /> {Circ) ne <br /> Transfer to Activ Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? De <br /> 2332-EXEMPT TANK FACILITY PR0503170 EE0000451 -STEVE SASSON Inactive Y N A I D <br /> 2951 -UGT-CAP PR0004367 EE0000684-MICHAEL INFURNA AcVk Y N A (DID <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSIEHD 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 1 I <br /> Program Records to be TRANSFERED: "$20.00= Amount Paid Date I I <br /> Water System to be TRANSF RED: '$150.00= Amount Paid Date I I <br /> Payment T Check Number Credit Card Number Received by <br /> REHS: Date 2A D .1 Account out: Date O�I ';q-t /�� <br /> COMMENTS: <br /> IIPHS-EHSOL-NTIAPPSIEnvisions\Client Access\ENVISIONIREPO <br />