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Date mn 10/31/2017 2:25:41 P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/31/2017 <br /> Record Selection Critena: Facility ID FA0016688 <br /> Make changeslcorrections 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 OW0013529 New Owner ID <br /> Owner Name JASPER VAN VLIET <br /> Owner DBA JASPER VAN VLIET <br /> OwnerAddress 17651 DODDS RD <br /> ESCALON, CA 95320 <br /> Home Phone Not Specified <br /> Work/BusinessPhone 209-531-5477 <br /> Mailing Address 17651 DODDS RD <br /> ESCALON, CA 95320 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0016688 10185245 <br /> Facility Name JASPER VAN VLIET <br /> Location 17651 DODDS RD <br /> ESCALON, CA 95320 <br /> Phone 209-531-5477 x0 <br /> Mailing Address 17651 DODDS RD <br /> ESCALON, CA 95320 <br /> Care of JASPER VAN VLIET Inc <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 004-WINN, CHARLES Fax <br /> APN 20318009 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 AR0029570 NewAccount ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name JASPER VAN T /J I (Circle One) <br /> Account Balance as of 10/31/2017: 5.00 (J <br /> (Circe One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> X518--HM-Farm Operations <br /> - PR0524873 EE0002670-MUNIAPPA NAIDU Active Y N A I D <br /> 2220 M HW GEN<5 TONS/YR PRO530165 EE0000032-JOHN ALANIZ Active Y N A I D <br /> AST EXEMPT FAC <1,320 GAL PR0530164 EE0002670-MUNIAPPA NAIDU Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO532091 Irlactive 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 speck,PHSEHD 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 andlor Standards and State and'or <br /> Federal Laws. I <br /> APPLICANT'S SIGNATURE: V L o, 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 Received k/w', <br /> EHD Staff: Al I /✓f�� Date�/ 3/ // Account out: N Date ,9 13) lI <br /> COMMENTS: y <br /> Dice#: <br />