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Date run 5/181201E 8:47:28An SAN JOA64/IN COUNTY ENVIRONMENTAL HEALL,,illIUlEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 5/18/2015 <br /> Record Selection Criteria: Facility ID FAD022943 <br /> Make changes/corrections 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 OW0020948 New Owner ID <br /> Owner Name RJM Vineyards, LLC <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-545-1623 <br /> Mailing Address 5206 Hammett Road <br /> Modesto, CA 95366 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0022943 10483951 <br /> Facility Name Pacific Agril-ands, Inc. <br /> Location 16121 Liberty Rd <br /> Galt, CA 95632 <br /> Phone 209-545-1623 x <br /> Mailing Address 5206 Hammett Road <br /> Modesto, CA 95358 <br /> care of Ernest Dosio <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 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 AR0042068 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Ernest Dosio (Circle one) <br /> Account Balance as of 5/18/2015: $0.00 <br /> (Circle One) <br /> Transfer to ActiveMacive <br /> Program/Element and Description Record ID Employee ID and Name status New OwneR Delete <br /> 1958-HM-Farm Operations PRO540123 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO540122 EE0001422-ARIS VELOSO Active 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,PHS(EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form, l also certify that all operations will be performed in accordance with all applicable Ordinance Codes andror Standards and Stateandor <br /> Federal Laws <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date I / <br /> Water System to be TRANSFERED: Amount Paid Date I / <br /> Payment Type Check Number Received by <br /> EHD Staff: Date / _/l— Account out: Date <br /> COMMENTS: Invoice 1#: <br /> G2C^A-iL-0 NCJ FPV-rA L,t,1v1 d- 2 v,A Ck-rilLs - <br /> (S t J C4+e-w.5 -, <br />