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Date run 2{1412014 4:2;Z51PA SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#wzt <br /> Run by Pagel <br /> Facility Information as of 2/14/2014 <br /> Record Selection Criteria- Facility ID FA0016984 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0013825 New Owner ID <br /> Owner Name MANUEL DUTRA <br /> Owner DBA MANUEL J DUTRA JR. <br /> Owner Address 10806 N LOWER SACRAMENTO RD <br /> STOCKTON, CA 95210 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 10806 N LOWER SACRAMENTO RD <br /> STOCKTON, CA 95210 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID{CERS ID FA0016984 10,185,715 <br /> Facility Name MANUEL DUTRA <br /> Location 10806 N LOWER SACRAMENTO RD <br /> STOCKTON, CA 95210 <br /> Phone 209-477-4567 x0 <br /> Mailing Address 10806 N LOWER SACRAMENTO RD <br /> STOCKTON, CA 95210 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 08405003 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 AR0029866 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner { Facility J Account <br /> Account Name MANUEL DUTRA (Circle One) <br /> Account Balance as of 211412014: S53-:,0-&=-- <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 195B-HM-Farm Operations PRO525169 Active Y N AD <br /> 2840-AST EXEMPT FAC < 1,320 GAL PR0530431 EE0000753-WILLY NG Active,! Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532688 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,.operator or agent of same,acknowledge that all site,andlor project specific,PHSIEHD hourly charges associated with this facility or; <br /> 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 ani standards and State and/or 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 bu <br /> REHS: Date 1_�1 Account out: Date ! ! <br /> COMMENTS: Z^jam <br /> A <br />