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Date rug 9X212014 4:36:55PR SAN JO16.01JIN COUNTY ENVIRONMENTAL HEALJDEPARTMENT Report#5021 <br /> Run by 1273 Pagel <br /> Facilityinformation as of 9/22/2014 <br /> Record Selection Criteria: Facility ID FA0022460 <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 OW0019888 New Owner ID <br /> Owner Name Ronn and Lance Leffler <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-986-1045 <br /> Mailing Address 6488 E Eight Mile Rd <br /> Stockton, CA 95212 <br /> Care of <br /> FACILITY FILE INFORMATION �r <br /> Facility ID/CERS ID FA0022460 10421899 CS� <br /> Facility Name i0rini Bears Ranch, LLC <br /> Location 6488 E Eight Mile Rd <br /> Stockton, CA 95212 <br /> Phone 209-986-1045 x <br /> Mailing Address 6488 E. Eight Mile Rd. <br /> Stockton, CA 95212 <br /> Care of Ronn and Lance Leffler <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 063-040-16 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 AR0041103 New Account ID: <br /> Mail Invoices to FaciliMail Invoices to: Owner / Facility / Account <br /> Account Name 'AnoAgBears Ranch, LLC (Circle One) <br /> Account Balance as of 9/22/2014: $360.00 <br /> (Circle One) <br /> Transfer to ActiveAnadve <br /> PmgramfElement and Description Record ID Employee ID and Name status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO539275 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT'. I,the undersigned owner,operator or agent of same,acknowledge that all site,andor 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 all operations will be performed in accordance with all applicable Ordinance Codes andor Standards am State anda <br /> Federal Laws. <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 Recei y <br /> REHS: Date / /_ Account out: Dale <br /> COMMENTS: <br />