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Date ran 115/2015 11:31:02AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Pagel <br /> Run by Facility Information as of 1/5/2015 <br /> Record Selection Criteria: Facility ID FA0017130 <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 OW0013971 New Owner ID <br /> Owner Name KIRSCHENMAN FARMS <br /> Owner DBA KIRSCHENMAN FARMS <br /> OwnerAddress `�`- e' <br /> LODI, CA 95242 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-649-8473 <br /> Mailing Address 13145 N LOWER SACRAMENTO RD <br /> LODI, CA 95242 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0017130 10185941 <br /> Facility Name KIRSCHENMAN FARMS <br /> Location. 17.\45 <br /> LODI, CA 95242 <br /> Phone 209-649-8473 x <br /> Mailing Address <br /> LODI, CA 95242 <br /> Care of john kirschenman <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 05806018 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 AR0030012 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name KIRSCHENMAN FARMS (Circle One) <br /> Account Balance as of 1/5/2015: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inadve <br /> Progra"Elemenl and Description Record ID Employee ID and Name Status New Omer? Delete <br /> 1958-HM-Farm Operations PRO525315 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2220-SM HW GEN<6 TONS/YR PR0530427 EE0001422-ARTS VELOSO Active Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PRO530426 EE0001 422-ARIS VELOSO Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532504 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ands r project specific,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 andiar Standards and State ands <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: °`t �y� Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Dale <br /> Payment Type Check Number Received by <br /> REHS: Date_/ / Account out: Date <br /> COMMENTS: QW <br />