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Date en /iL3/2009 1:08:01 PA SAN JOj -'IN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 4/13/2009 <br /> Record Selection Criteria: Facility ID FA0004113 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) 3 a <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0003022 New Owner ID <br /> Owner Name SAMBADO, LAWRENCE <br /> Owner DBA <br /> Owner Address 8077 N TULLY RD <br /> LINDEN, CA 95236 <br /> Home Phone 209-931-2568 <br /> Work/Business Phone Not Specified <br /> Mailing Address 8077 N TULLY RD <br /> LINDEN, CA 95236 <br /> Care of A SAMBADO & SON INC <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0004113 <br /> Facility Name A SAMBADO & SON 39-321 <br /> Location 14000 E EIGHT MILE RD <br /> LINDEN, CA 95236 <br /> Phone 209-931-2568 <br /> Mailing Address 8077 N TULLY RD <br /> LINDEN, CA 95236 <br /> Care of A SAMBADO & SON INC <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 09102005 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SAMBADO, A& SONS INC <br /> Title <br /> Day Phone 209-931-2568 60 <br /> Night Phone 209-931-2568 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003775 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name A SAMBADO & SON 39-321 (Circle One) <br /> Account Balance as of 4/13/2009: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2765-EMPLOYEE HOUSING-PERMANENT>180 D/PR0270321 EE0001421 -STACY RIVERA Active Y N A I D <br /> a <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 Ordinate 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 Rece'v d y <br /> REHS:, _ Date 0,175 / Account out: Date <br /> COMMENTS: <br /> On I <br /> l S © �-r° • N LL C{ -f-0 r (no r� <br /> 0�101 0o <br /> \\eh-env\envision\reports\5021.rpt ` <br />