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Date nm 7/29/2015 2:32:03PR SAN JO.' 'JIN COUNTY ENVIRONMENTAL HEAI 'DEPARTMENT Report#5021 <br /> Run by `/ \r/ Pagel <br /> Facility Information as of 7/29/2015 <br /> Record Selection Criteria: Facility ID FA0017441 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) ((�� <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0014282 New Owner ID <br /> Owner Name KATHERINE KELLY <br /> Owner DBA KATHERINE KELLY <br /> Owner Address 26565 COUNTRY RD 97D <br /> DAVIS, CA 95616 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 26565 COUNTY RD 97D <br /> DAVIS, CA 95616 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017441 10186455 <br /> Facility Name KATHERINE KELLY <br /> Location 10351 E ACAMPO <br /> LODI, CA 95240 <br /> Phone 530-758-9746 x0 <br /> Mailing Address 26565 COUNTY RD 97D <br /> DAVIS, CA 95616 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 01718010 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone le <br /> ACCOUNTS RECEIVABLE FILE INFORMATION A� <br /> Account ID AR0030323 t^' New Account ID: <br /> Mail Invoices to Owner S`° �-yQ/ Mail Invoices to: Owner / Facility / Account <br /> Account Name KATHERINE LLY ^6,v/ <br /> (Circle One) <br /> Account Balance as of 7/29/2015: $53. 0 / <br /> �,b� <br /> (Circle One) <br /> Transfer to Acfive/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PRO525626 EE0008709-JAMIE DE LA ROSA Active Y N AI D <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0528977 EE0001422-ARIS VELOSO Inactive Y N AD <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533870 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specific,PHS/EHD hourly charges associated with this facility <br /> 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 Ordinance Codes andror Standards and State andfor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date ! / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date 1 / <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received b <br /> EHD Staff: n/69t , Date�_/ /�� Account out: Date <br /> COMMENTS: <br /> Invoice#: <br /> f Z g J y i�t" 4f1 l injo►'1 f-arryi s 9 7 - <br />