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Data mnrg/J015 43237PM SAN JO 7IN COUNTY ENVIRONMENTAL HEA! t DEPARTMENT Report asort <br /> Run by *1"0 Pagel <br /> Facility Information as of 3/9/2015 <br /> Record Selection Criteria'. Facility ID FA0022453 <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 10 <br /> Owner ID OW0019877 New Owner ID <br /> Owner Name Bill Shinn <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-369-4292 <br /> Mailing Address P.O. BOX 1051 <br /> Woodbridge, CA 95258 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0022453 10413202 <br /> Facility Name J & J Shinn Ranch Shop <br /> Location 21500 N Davis Rd <br /> Lodi, CA 95242 <br /> Phone 209-369-4903 x <br /> Mailing Address RO. Box 1051 <br /> Woodbridge, CA 95258 <br /> care of J & J Shinn Ranch <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 013-080-410-001 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0041096 New Account ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name J & J Shin an h o (Circle One) <br /> Account Balance as of 3/9/2015: <br /> (Circle One) <br /> Transfer to Active/Inicive <br /> Program/Element and Description Record ID Employee ID and Name N\ ' Status New Owner? Delete <br /> 1958-HM-Farm Operations PR05392644, EE0008709-JAMIE DE LA ROSA Active Y N A Q D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owneroperator or agent of same,acknowledge that all site,ander project specific,PHSAEHD hourly charges associated with thia f s ility <br /> or activity will be bdl ed 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 ander Standards and antl S <br /> Federal Laws. 1'J Lip <br /> -7 —7 ` q/I �tn�� <br /> APPLICANT'S SIGNATURE: � /NV `���� ` �N� �� �� Dat <br /> Program Records to be TRANSFERED: —*$25.00=— Amount Paid Date / / ++ <br /> Water System to be TRANSFERED: Amount Paid Date / / ,yrwr <br /> Payment Type Check Number Received by <br /> 111,4-Y <br /> REHS: 44 - i .�Fy Date—3—/ 2 0/ / Account out: Date / 0 1 1 S <br /> COMMENTS: <br /> ✓�) �e f�SA P 7i-f-�'S <br />