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Date run 12/2/2008 10:14:16AI SAN JO/ 'IN COUNTY ENVIRONMENTAL HEAL ' DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/2/200b <br /> Record Selection Criteria: Facility ID FA0018722 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <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 FA0018722 <br /> Facility Name S C RANCH 39-425 <br /> Location 7 ;L- E7 64-" ' stlD G <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 09108015 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 AR0033238 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name S C RANCH 39-425 (Circle One) <br /> Account Balance as of 12/2/2008: $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 /> 2755-EMPLOYEE HOUSING PR0527631 EE0001421 -STACY RIVERA 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: 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 by <br /> REHS: (r Date OZ Account out: � Date <br /> COMMENTS: <br /> e4e Lwd ovi JoL"a4f c-r � 1 <br /> V <br /> \\phs-ehsql-nt\apps\envisions\reports\5021.rpt <br />