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Date run 12122/2014 4:24:33P SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMENT Report#5021 <br /> Paget <br /> Run by <br /> Facility Information as of 12/2212014 <br /> Record Select§on Criteria: Facility ID FA0017078 <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/Fed Tax ID <br /> Owner ID O`,1V0013919 New Owner ID <br /> Owner Name DODDS ORCHARD <br /> Owner DBA DODDS ORCHARD <br /> Owner Address 9749 E FAIRCHILD <br /> STOCKTON, CA 95215 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-931-4631 <br /> Mailing Address 9749 E FAIRCHILD RD <br /> STOCKTON, CA 95215 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0017078 10135859 <br /> Facility Name DODDS ORCHARD <br /> Location 9749 E FAIRCHILD RD <br /> STOCKTON, CA 95215 <br /> Phone 209-931-4631 x <br /> Mailing Address 9749 E FAIRCHILD RD <br /> STOCKTON,, CA 95215 <br /> Care of MARY DODDS <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 08924017 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 AR0029960 New Account ID: <br /> Mail Invoices to Owner Maif Invoices to: Owner I Facility ! Account <br /> Account Name DODDS ORCHARD (Circle One) <br /> Account Balance as of 12/22/2014: $0.00 <br /> (Circle One) <br /> Transfer to Activefinactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PR0525263 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2840-AST EXEMPT FAC < 1,320 GAL PR0529715 EE0000753-WILLY NG Inactive Y N A I D <br /> E'RSC-ELECTRONIC REPORTING STATE SURCHARG PRO534414 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT, I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSIEHO 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. <br /> APPLICANT'S SIGNATURE: Date -I-/- <br /> Program <br /> 1Program Records to be TRANSFERED: '$25.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date I I <br /> Payment Type Check Number Received by <br /> REHS: Date ! l Account out: Date I 1 <br /> COMMENTS: <br />