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Date ran 2/11/2014 3:58:42PA $AN 3C JIN COUNTY ENVIRONMENTAL HEAD DEPARTMENT Rep°°#5112/ <br /> Pagel <br /> Run by 1273 `o, <br /> Facility Information as of 2/11/2014 <br /> Record Selection criteria: Facility ID FA0017032 <br /> Make changestcorrections In RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0013873 New Owner ID <br /> owner Name LARRY PELLEGRI FARMS <br /> owner DBA LARRY PELLEGRI FARMS <br /> Owner Address 2307 CALHOUN WAY <br /> STOCKTON, CA 952073306 <br /> Home Phone Not Specified <br /> WorktBusiness Phone Not Specified <br /> Mailing Address 2307 CALHOUN WAY <br /> STOCKTON, CA 952073306 i,,;u:� ' mrr <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0017032 10,185,787 <br /> Facility Name LARRY PELLEGRI FARMS <br /> Location 6588 W JACOBS RD <br /> STOCKTON, CA 95206 <br /> Phone 209-463-7079 x0 <br /> Mailing Address 2307 CALHOUN WAY I-7 117 [ LLS[ D <br /> STOCKTON, CA 952073306 <Au 44 fte-4 P,29 - awp <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 005 - ELLIOTT, BOB Fax <br /> APN 13124004 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 AR0029914 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner I Facility / Account <br /> Account Name LARRY PELLEGRI FARMS (circle One) <br /> Account Balance as of 2/11/2014: $266.00 <br /> (Circle One) <br /> Transfer to Active/InaeNe <br /> PrograMElement and Description Record ID Employee ID end Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PRO525217 Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO530935 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PRO530934 EE0001421 -STACY RIVERA Active,/ Y N A 1 D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532020 Inactive 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 andbr Standards and Slate and'or <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 Remi <br /> REHS: y �Date / J{//�// A/cco,{unt out: Date / 1 / <br /> COMMENTS: J[yy��� U `SLC/(.CiV.' � /• `e"�...�' r <br /> COY <br />