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Date mo 12/4/2014 9:35:01AK SAN JO. )IN COUNTY ENVIRONMENTAL HEAL` DEPARTMENT Reportl5021 <br /> Run by Pagel <br /> Facility Information as of 12/4/2014 <br /> Record Selection Criteria: Facility ID FA0020355 <br /> Make changeslcorrections 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 OW0016713 New Owner ID <br /> Owner Name O&O JIMENEZ FARM <br /> Owner DBA O&O JIMENEZ FARM <br /> Owner Address 22355 N HWY 99 <br /> ACAMPO, CA 95220 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 22355 N HWY 99 <br /> ACAMPO, CA 95220 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0020355 10187591 <br /> Facility Name O&O JIMENEZ FARM <br /> Location 22355 N HWY 99 <br /> ACAMPO, CA 95220 <br /> Phone 209-333-1572 x0 <br /> Mailing Address 22355 N HWY 99 <br /> ACAMPO, CA 95220 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 01319021 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0036342 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name O&O JIMENEZ FARM (Circle One) <br /> Account Balance as of 12/4/2014: $0.00 <br /> (Circle One) <br /> Transfer to Ac* Wlnacrve <br /> Program/Element and Description Rewrd ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PRO535240 Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0535264 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 protect specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to Die 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 antl State anNor <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 /> REHS: Date_/ / Account out: Date_/ / <br /> COMMENTS: <br />