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Date run 7/2/2015 8:41.46AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/2/2015 <br /> Record Selection Criteria Facility ID FA0023018 <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 OW0021055 New Owner ID <br /> Owner Name STONUM, MICHAEL <br /> Owner DBA <br /> Owner Address 16388 N ALPINE RD <br /> LODI, CA 95240 <br /> Home Phone 209-368-1772 <br /> Work/Business Phone Not Specified <br /> Mailing Address 16388 N ALPINE RD <br /> LODI, CA 95240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0023018 <br /> Facility Name STONUM VINEYARDS INC <br /> Location 16388 N ALPINE RD <br /> LODI, CA 95240 <br /> Phone <br /> Mailing Address 16388 N ALPINE RD <br /> LODI, CA 95240 <br /> Care of STONUM, MICHAEL <br /> Location Code 99- UNINCORPORATED d Alt Phone <br /> BOIS District 004 -WINN, CHARLES Fax <br /> APN 05107002 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 AR0042226 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name STONUM VINEYARDS INC (circle one) <br /> Account Balance as of 7/2/2015: $0.00 <br /> (Circle One) <br /> Transrer to Acbhe/Inacive <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PR0540258 EE0008709-JAMIE DE LA ROSA Active Y N A (� D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT'. I,the undersigned owner,operator or agent of same,acknowledge that all site,anchor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this forth. I also certHy that all operations will be performed in accordance with all applicable On inane Codes anchor Standards and State anchor <br /> Federal Laws. <br /> APPLICANT'S 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 NumberReceived by <br /> EHD Staff: Date__^'1-1-2-1J.`� Account out: Date <br /> COMMENTS <br /> IDVOICe ff: <br />