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Date run 4/16/2009 2:40:58PN SAN JOIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 4/16/200 <br /> Record Selection Criteria: Facility ID FA0018712 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) SA 4`? <br /> OWNERSHIP CHANGE(date) 01'1! <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0015380 New Owner ID : <br /> Owner Name S}ER-Rpr C- W C-I- rArids <br /> Owner DBA <br /> Owner Address 4343 MCKINLEY AVE 4 2 0 CA S4 Sou /' n A t/Zh vre <br /> STOCKTON, CA 95206 TBrndJ.e /{ Z $$2 Sa <br /> Home Phone 602-792-0275 1 800 3Se2-.3a2y$ <br /> Work/Business Phone 209-982-4936 <br /> Mailing Address PO BOX 31750 Po <br /> STOCKTON, CA 95213 T.em <br /> Care of SIERRA ORGANICS <br /> FACILITY FILE INFORMATION a&`A � vi tE' �kc. cEOYN <br /> Acc-� 5 {���1�o�2. ; �i n. <br /> Facility ID FA0018712 �1 <br /> Facility Name 676 — well rand S <br /> Location 4343 S MCKINLEY AVE <br /> STOCKTON, CA 95206 <br /> Phone 209-982-4936 <br /> Mailing Address PO BOX 31750 <br /> STOCKTON, CA 95213 <br /> Care of PACKER, BOB <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 001 - GUTIERREZ, STEVE Fax ?��— L f}(J <br /> APN 19302009 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 AR0033228 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name SIERRA ORGANICS (Circle One) <br /> Account Balance as of 4/16/2009: $420.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2244-PACT TRANSFER RECORD-OES PR0522284 EE0000000-HAZ MAT SJC OES Inactive N A I D <br /> 4443-SW COMPOST SITE PR0523714 EE0004680-NATALIA SUBBOTNIKO'Active Y i 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: *$372.00= Amount Paid Date <br /> Payment Type Check Number Received y <br /> REHS: If tr(iSP C C Date 'fit—f�fx-16 <br /> �—C 1 Account out: Date <br /> COMMENTS: S '/O('16-1 <br /> \\eh-env\envision\reports\5021.rpt <br />