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Date run 7/8/2015 9:07:19AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/8/2015 <br /> Record Selection Cnleda: 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 /6 G 9(n <br /> ACAMPO, CA 95220 L d l . C A <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 ID/CERS ID FA0017139 10185957 <br /> Facility Name DAVID GAUDET BEEKEEPING SERVICE <br /> Location 1481 E ACAMPO RD <br /> ACAMPO, CA 95220 1 A 6 14 6 F OsC <br /> Phone 209-368-5465 x0 95L -`I7 <br /> Mailing Address 1481 E ACAMPO RD <br /> ACAMPO, CA 95220 <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004-WINN, CHARLES Fax <br /> APN 01314048 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 AR0030021 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name DAVID GAUDET BEEKEEPING SERVIC (Circle One) <br /> Account Balance as of 7/8/2015: $226.00 <br /> (Circle One) <br /> Transfer to Activellnafire <br /> Program/Element and Description Record ID Employee to and Name Status New Ovmi Delete <br /> 1958-HM-Farm Operations PR0525324 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 PRO531780 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS/El hourly charges associated with this facility <br /> or activity will be billed to the parry identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Lewis <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 Re <br /> EHD Staff: Date / / Account out: Date 7 1 Z/ l� <br /> COMMENTS: <br /> Invoice#: <br />