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Date mni 2/1912014 11:36:12AI SAN JO vM COUNTY ENVIRONMENTAL HEAT�DEPARTMENT Rapers#5021 <br /> Run by Pagel <br /> Facility Information as of 2/19/2014 <br /> Regard Selection Criteria: Facility ID FA0017157 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0013998 New Owner ID <br /> Owner Name K&K FARMS <br /> Owner DBA K&K FARMS <br /> Owner Address 18747 N DEVRIES RD <br /> LODI, CA 95242 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address PI) —k3iC.SS( <br /> -6e0l-� W onr�hndar. CA of S SR <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0017157 10,185,987 <br /> Facility Name K&K FARMS <br /> Location 18747 DEVRIES RD <br /> LODI, CA 95242 <br /> Phone 209-403-1080 xO 1� <br /> Mailing Address 1�47 t DE-VRIES RD-- <br /> 1:01121t,-CA-95242 <br /> D L,01121t,-CA-95242 ',JOCAbrt ae, loi <br /> Care of <br /> Location Code 99-UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 01304011 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 AR0030039 New Account ID: <br /> Mail lnvoicesto Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name K&K FARMS (circte One) <br /> Account Balance as of 2/19/2014: $53.00 <br /> (Clrue One) <br /> Transfer to Activelinactve <br /> Program/Element and Description Record ID Employee ID and Name Status New OwneR Delete <br /> 1958-HM-Farm Operations PRO525342 Active Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PRO529593 EE0000753-WILLY NG Active,l Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO534764 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACIQIOWLEDGEMENi: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity,will be billed to the party identified as the OWNER on thie form. I also gentry that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State ands <br /> Federal Lawa <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 Receiv by <br /> REHS: Date /_/ Account out: Date Zile <br /> COMMENTS. <br />