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Date run 7/8/2015 9'.15:14AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by e <br /> Facility Information as of 7/8/2015 Pagel <br /> Record Selection Criteria: Facility ID FA0017139 <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 OW0013980 New Owner ID <br /> Owner Name DAVID GAUDET BEEKEEPING SERVIC <br /> Owner DBA DAVID GAUDET BEEKEEPING SERVIC <br /> Owner Address 1481 E ACAMPO RD <br /> ACAMPO, CA 95220 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 1481 E ACAMPO RD <br /> ACAMPO, CA 95220 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0017139 10185957 <br /> Facility Name DAVID GAUDET BEEKEEPING SERVICE _ <br /> Location 1481 E ACAMPO RD <br /> ACAMPO, CA 95220 <br /> Phone 2 <br /> Mailing Add s 1481 E ACAMPO RD / _ 7 <br /> ACAMPO, CA 95220 <br /> C f <br /> Location Cod PORATED P Alt Phone <br /> BOS District 004-WINN, CHARLES Fax <br /> APN 01314048 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone �QA rn J <br /> ACCOUNTS RECEIVABLE FILE INFORMATION ` ~ S • 130 *1p/-Q-� <br /> Account ID AR0030021ZjlI� New Account ID: <br /> Mail Invoices to Owner v"tr1fJ1� Off" Mail Invoice to: Owner / Facility / Account <br /> Account Name DAVID GAUDET BEEKEEyyPP[[ING SERVIGGGGrr Circle One) <br /> Account Balance as of 7/8/2015: $226.00 <br /> (Circle One) <br /> ProgramiElement and DescriptionRecwd ID Employee ID and Name Status Transfer to Activelaraci <br /> New Owner? Delete <br /> 1958-HM-Farm Operations PRO525324 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PRO528948 EE0002670-MUNIAPPA NAIDU Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0531780 InactivE Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSi hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also canny,that all operations will be performed in accordance with all applicable Ordinance Codes and(cr Standards and State ani <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received y <br /> EHD Staff. ��Ol. Date--a-/-ZA-_/--125E-Account out: Date <br /> COMMENTS: <br /> _ Invoice#: <br /> `PI tom- <br /> JAIL/ halt- ti <br />