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Datefun 2/21/2013 3:00:32PR SAN JO. IN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by `l/ <br /> Pagel <br /> Facility Information as of 2/21/2013 <br /> Record Selection Criteria. Facility ID FA0017046 <br /> Make changesicorrections in RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSNI Fed Tax ID <br /> Owner ID OW0013887 New Owner ID <br /> Owner Name TEIXEIRA DAIRY <br /> Owner DBA TEIXEIRA DAIRY <br /> Owner Address 2455 NAGLEE RD <br /> TRACY, CA 95304 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 2455 NAGLEE RD <br /> TRACY, CA 95304 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017046 <br /> Facility Name TEIXEIRA DAIRY <br /> Location 21150 MT HOUSE PKWY <br /> TRACY, CA 95304 <br /> Phone 209-836-4081 x0 <br /> Mailing Address 2455 NAGLEE RD <br /> TRACY, CA 95304 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 20915021 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name ye <br /> Title <br /> Day Phone 5i <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0029928I . ! New Account ID: <br /> Mail Invoices to Owner l.�` Mail Invoices to: Owner / Facility / Account <br /> Account Name TEIXEIR 5 (u(� (Circle One) <br /> Account Balance as of 2/21/2013: $ .00 <br /> (Circle One) <br /> Trintterto Active/Inal <br /> Progra"Element and Description Record ID Employee ID and Name Statue New Owner? Delete <br /> T958-HM-Farm Operations PR0525231 ActivQ Y N AD <br /> 2i2 SM HW GEN<5 TONS/YR PRO530995 EE0002646-THUY TRAN -Aetive Y N A I D <br /> ,Q239 AST FAC -SPCC EXEMPT PRO530994 EE0002646-THUY TRAN div Exempt Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPR0533440 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,ander 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 certify that all operations will be Performed in accordance with all applicable Ordinance Codes ander Standards and State and'or <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 <br /> Payment Type —Check Number Recei <br /> REHS: n.Jl 4T/7 ry�y� Date <br /> I //y��L 1A^cc�ouln�t o/ut,:, y [>0,r�/],�/D1a"te�- N-0/ yA�-�'/"�1�,r, '1r�tr'1 s <br /> COMMENTS: Ir `t � /FQU'l \•t�tJc�IJr"1 o` IS'l \✓t /�t0�1�{f.(AQ..f�i�1'C! L�I���L.�k.�l1�ir�r 41" `/ /�r�4(�`rt <br /> or1J <br /> (Zug, 21x2 13 <br />