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Dale run 2/17/2015 `55:43AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT R�P^� l <br /> Run by <br /> Facility Information as of 2/17/2015 Papel <br /> Record Selection criteria: Facillty 10 FA0005381 <br /> Make changes/correc0ons in RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 <br /> SSN/Fed Tax ID <br /> Owner ID OW0004224 New Owner ID <br /> Owner Name J LOMBARDI FARMS <br /> Owner DBA J LOMBARDI FARMS <br /> Owner Address 16998 E GAWNE RD <br /> STOCKTON, CA 95215 <br /> Home Phone 209-649-0017 <br /> Work/Business Phone 209-948-1909 <br /> Mailing Address 16998 E GAWNE RD <br /> STOCKTON, CA 95215 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0005381 10181815 <br /> Facility Name J LOMBARDI FARMS <br /> Location 29665 KASSON RD <br /> TRACY, CA 95376 <br /> Phone 209-948-1964 <br /> Mailing Address 16998 E GAWNE RD <br /> STOCKTON, CA 95215 ryl <br /> Care of <br /> Location Code 99 - UNINCORPORATED P All Phone <br /> BOS District 005 - ELLIOTT, BOB Fax <br /> APN 25527052 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 AR0005843 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name J LOMBARDI FARMS (ClrcleOne) <br /> Account Balance as of 2/17/2015: $292.00 <br /> ��\ (Circle One) <br /> Transfer to Active/InacNe <br /> ProprartdElement and Dasalpllan Record ID Employee ID and Name �1�, Status New Owner? Delete <br /> 1958-HM-Fa O eratlons PR0525644 EE0002474- SI Active Y N A /�b/'(� D <br /> 22 - M HW GEN<5 TONS/YR PRO529364 EE0009001 -ELE A MANZO Active Y N A Cl/ D <br /> 2333- ITY-obsolete PR0502269 EE0000451 - Inactive Y N A D <br /> 2630-AST FAC -SPCC EXEMPT PRO529363 EE0009001 -ELENA MANZO Active Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO531371 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of some.acknowledge that all all anclor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party Identified as the OWNER on this form._I also certily that all operations will be performed in accordance with all applicable Ordinance Codes anNur Standards and State and'or <br /> Federal Laws. �7 <br /> APPLICANTS SIGNATURE: Date O— / /l <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 Received b _ <br /> REHS: Nil - A/4//�7� Date---LJ—L-01—L5 Account out: _I Date_ 11 D S <br /> COMMENTS: <br /> PtxAsc- 5;A77A«cJ <br /> 2V14l . /I'D <br />