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Date run 2/16/2016 2:45:13PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 2/16/2016 <br />Record Selection Criteria: Facility ID FA0016779 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID <br />OW0013620 <br />Owner Name <br />MIKE GIKAS FARMS <br />Owner DBA <br />MIKE GIKAS FARMS <br />Owner Address <br />14022 S AUSTIN RD <br />MANTECA, CA 95336 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />14 D <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0016779 10185391 <br />Facility Name <br />MIKE GIKAS FARMS <br />Location <br />14022 S AUSTIN RD <br />MANTECA, CA 95336 <br />Phone <br />209-823-4928 x0 <br />Mailing Address <br />1 D <br />MANTE6A, 6A 95336 <br />Care of <br />Location Code 99 - UNINCORPORATED P <br />Bos District 005 - ELLIOTT, BOB <br />APN 20607003 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0029661 <br />Mail Invoices to Owner <br />Account Name MIKE GIKAS FARMS <br />Account Balance as of 2/16/2016: $53.00 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN /Fed Tax ID <br />New Owner ID : <br />C2 rJ � <br />19013 <br />��4✓VlPSf>t.% <br />L-A <br />Alt Phone <br />Fax <br />EMail : <br />Mail Invoices to: <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inacive <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1958 - HM -Farm Operations PR0524964 EE0002670 - MUNIAPPA NAIDU Active Y N A I D <br />2830 - AST FAC - SPCC EXEMPT PR0529049 EE0009001 - ELENA MANZO Inactive Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0534747 Inactive 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 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 and/or Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />EHD Staff: <br />COMMENTS <br />* $25.00 = <br />Date <br />Date <br />Amount Paid Date <br />_ Amount Paid Date <br />Received by <br />Account out: Date d lL�I�G <br />Invoice #: <br />rev' ReJL'4-�') <br />,Mr", <br />