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Date run 2/16/2016 2:55:02PN 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 FA0022741 <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 OW0020527 New Owner ID <br />Owner Name Tim mcklnsey <br />Owner DBA <br />Owner Address <br />Home Phone Not Specified <br />Work/Business Phone 209-996-3314 <br />Mailing Address ' e <br />361 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0022741 10612708 <br />Facility Name <br />Tim Mcklnsey <br />Location <br />22150 Burwood Rd <br />Escalon, CA 95320 <br />Phone <br />209-996-3314 x <br />Mailing Address <br />7 <br />O <br />Care of <br />Tim mcklnsey <br />Location Code <br />BOS District <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0041682 <br />Mail Invoices to Account <br />Account Name Tim McKinsey <br />Account Balance as of 2/16/2016: $53.00 <br />I t9C, l 4 "Ci e0 C, `eN Cl+ <br />ll9`1( e0C <br />e 36 <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 />Transferto Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1958 - HM -Farm Operations PR0539753 EE0002670 - MUNIAPPA NAIDU Active 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 alp 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 c,2, � <br />Invoice #: <br />LkCtNS-%'6 eJ c,.dClr e 5 cc S 0t ✓' �� �►—r-/ t^^ � � <br />