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Data run 10/12/2017 11:21:48/ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by f , <br /> Facility Information as of 10/12/2017 Pagel <br /> Record Selection criteria: Facility ID FA0016739 <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 OW0013580 New Owner ID <br /> Owner Name WILLIAM ELSHOLZ <br /> Owner DBA WILLIAM ELSHOLZ <br /> Owner Address 20656 N KENNEFICK RD <br /> ACAMPO, CA 95220 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-368-0435 <br /> Mailing Address 20656 N KENNEFICK RD <br /> ACAMPO, CA 95220 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0016739 10185329 <br /> Facility Name WILLIAM ELSHOLZ <br /> Location 20656 N KENNEFICK RD <br /> ACAMPO, CA 95220 <br /> Phone 209-327-2193 x <br /> Mailing Address 20656 N KENNEFICK RD PD 60 y- 1 g -7 <br /> ACAMPO, CA 95220 0 67ir a 0 Care of William Elsholz <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 01714001 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 AR0029621 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name WILLIAM ELSHOLZ (Circle One) <br /> Account Balance as of 10/12/2017: $96.00 <br /> (Circle One) <br /> Progra"Elemenl and Description Record ID Employee ID and Name Status Transfer to Activellrni <br /> New Owner? Delete <br /> 1958-HM-Farm Operations PR0524924 EE0002670-MUNIAPPA NAIDU Active Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0530442 EE0000753-WILLY NG Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532109 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,PHSrEHD hourly charges associated with this facility <br /> or activity will be billed to the perry identified as the OWNER on this tonn. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes ani Standards and Stale ander <br /> Federal Laws. <br /> APPLICANT'S 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 Received by <br /> EHD Staff: Date /_ Account out: Date D / 2 / 7 <br /> COMMENTS: <br /> Invoice#: <br />