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Date run 3/23/2018 11:17:49Ah SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility/ Information as of 3/23/2018 <br /> Record Selection Criteria: Facility ID FA0017463 <br /> Make changesjcorrections 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 OW0014304 New Owner ID <br /> Ownef Name COUNTRYSIDE FARMS <br /> Owner DBA <br /> Owner Address 6666 E MAIN ST <br /> STOCKTON, CA 95215 <br /> Home Phone 209-484-5480 <br /> Work/Business Phone 209-471-5480 <br /> Mailing Address 6666 E MAIN ST <br /> STOCKTON, CA 95215 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0017463 10186479 <br /> Facility Name COUNTRYSIDE FARMS <br /> Location 6666 E MAIN ST <br /> STOCKTON, CA 95215 <br /> Phone 209-603-6690 x0 <br /> Mailing Address 6666 E MAIN ST <br /> STOCKTON, CA 95215 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> Al 10305001 El <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID ARD030345 i7 New Account ID: <br /> Mail Invoices to Owner Maii Invoices to: Owner I Facility / Account <br /> Account Name COUNTRYSIDE FARMS { i\` (Circle One) <br /> Account Balance as of 3/23/2018: $1,126.00 �f <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owrer? Delete <br /> 1958-HM-Farm Operations PRO525648 EE0002670-MUNAPPA NAI DU Active Y N A e% D <br /> 2220-SM HW GEN<5 TONSIYR PRO530593✓ EE0000031 -ELIANNA FLORIDO Active Y N A D <br /> 2840-AST EXEMPT FAC <1,320 GAL PRO530592 EE0009488-JEFFREY WONG Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE PRO533821 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,PF S7EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form I also cert that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 I <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date ! <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> El CxSc a/ Date 3 1. C I y8 Account out: Date <br /> COMMENTS: r I <br /> �G$ee� or �3��sfi� r�spe��'tol� Invoice#: <br />