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Date run 4/26/2016 11:41:OOAI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 4/26/2016 <br /> i <br /> Record selection Criteria: Facility ID FA0017261 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN I Fed Tax ID <br /> Owner ID OW0014102 New Owner ID <br /> Owner Name M&R ZOLEZZI <br /> Owner DBA M&R ZOLEZZI <br /> owner Address 17787 E FRONT ST <br /> LINDEN, CA 95236 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address POBOX 39 <br /> LINDEN, CA 95236 Lty'AX, <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017261 10186167 <br /> Facility Name M&R ZOLEZZI <br /> Location 0 N EIGHT MILE 112 MI W JACK RD <br /> LINDEN, CA 95236 <br /> Phone 209-931-0291 x0 <br /> Mailing Address POBOX 39 D GG-k Z <br /> LINDEN, CA 95236 eL- � � r "z�_- 2C <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 06507038 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 AR0030143 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility 1 Account <br /> Account Name M&R ZOLEZZI /A)0 (Circle One) <br /> Account Balance as of 412612016: $266. /0-1 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> ProgramfElement and Description Record ID Employee ID and Name status New Owner? Delete <br /> HM-f=arm Operations PR0525446 EE0002670-MUNIAPPA NAIDU Active Y N A I D <br /> 222 SM HW GEN<5 TONS/YR PR0530382 EE0001422-ARIS VELOSO Active Y N A I D <br /> 40-AST EXEMPT FAC <1,320 GAL PRO630381 EE0001422-ARIS VELOSO Inactil Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0531264 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHSlEHD hourly charges associated with this facility or, <br /> 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 andior Standards and State andror Federal Laws. <br /> APPLICANT'S SIGNATURE: Date ! ! <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date f ! <br /> Water System to be TRANSFERED: Amount Paid Date I J <br /> Payment Type Check Number Received by <br /> EHD Staff: M �`7 (dyG. Date ! _! 1 Account out: Date 47-111-77 / <br /> COMMENTS: U�V ' �" �� � � Invoice#: <br />