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Date run 6/16/2010 9:08:40AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 715021 <br /> Run by Pagel <br /> Facility Information as of 6/16/2010 <br /> Record Selection Criteria: Facility ID FA0015246 <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 OW0012223 New Owner ID <br /> Owner Name JEPSEN WEBB RANCH LLC <br /> Owner gBA JEPSEN WEBB RANCH LLC <br /> Owner Address 7200 W 11TH ST <br /> TRACY, CA 95377 <br /> Home Phone 209-835-9491 <br /> Work/Business Phone Not Specified <br /> Mailing Address 7200 W 11TH ST <br /> TRACY, CA 95377 <br /> Care of KAGEHIRO, RUSSELL <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID F 0015246 <br /> Facility Name M VE- OFFSITE <br /> Location 17950 W VIA NICOLO RD <br /> TRACY, CA 95377 <br /> Phone <br /> Mailing Address 7200 W 11TH ST <br /> TRACY, CA 95377 <br /> Care of KAGEHIRO, RUSSELL <br /> Location Code 99- UNINCORPORATED P Alt Phone P <br /> BOS District 005-ORNELLAS, LEROY Fax A JI-zz <br /> APN 20911032 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0026232 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner I Facility I Account <br /> Account NamKEt EDY/JENKSCONSULTANTS (Circle One) <br /> Account Balance as 6/16/2010: $0.00 <br /> (Circe One) <br /> Transferlo Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name atu New Owner? Delete <br /> 2950-ENVIRON ASSESS R0522383 EE0000684-MICHAEL INFURNA A I Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the untl r,operator or agent of same,acknowledge that all site,and/ proje specific,PHS/EHD hourty 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 accor once 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 TRAN FERED: '$20.00= Amount Paid Date <br /> Water System to be N ERED: `$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date <br /> _�r jfib/ �O <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt r-` <br />