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Dale run 8124/2017 4:05:13Pk SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by DONNA Pagel <br /> Facility Information as of 8/24/2017 <br /> Record Selection Criers: Facility ID FA0016882 <br /> Make changeslcorrections In RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(dale)- <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0013723 New Owner ID <br /> Owner Name DA COSTA FARMS <br /> Owner DBA D A COSTA FARMS <br /> Owner Andress "1591$-E-HWY T20-- k 61`9 O 5F I'yu y LCA <br /> RIPON, CA 95366 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 185 <br /> ESCALON, CA 95320 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facil' /CERSID FA0016882 10185561 <br /> Facility Name DA COSTA FARMS / <br /> Location 15805 E HWY 120 14 l ! —/ Y / <br /> Phone 2090N, CA 9_513066 'rb!146 <br /> Mailing Addre T IS'805' L Hv4ty 120 <br /> RIPON, CA 95366 <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> Bos District 004-WINN, CHARLES Fax <br /> APN 20308015 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 AR0029764 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name D A COSTA FARMS (Clmle One) <br /> Account Balance as of 8/24/201 Z $80.00 <br /> -80.00 <br /> (Clyde One) <br /> Transfer to Activellnadve <br /> Program/Element and Description'-- _.. Record ID Employee lD and Name Status New Owner? Delete <br /> _ _1958-HM-Farm Operations - PRO525067 EE0002670-MUNIAPPA NAIDU Active Y N A D <br /> 28'40--ASTEXEMPT FAC <1,320 GAL PR0529603 EE0000753-WILLY NG Inactive Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO533132 Inactive Y N A D <br /> BILLING.and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all elle,endlor protect specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party Identified as the OWNER on this farm 1 also certify that all operations will be performed In accordance with all applicable Ordinance Codes and'ar Standards and State andlor <br /> Fedeml 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 /> EHD Staff: ✓V I �w-n ��-r� Dale Account out: Date / <br /> COMMENTS: <br /> Invoice#: <br /> revcr�cx -fib ALeu412%, a4Re") w4,o restcicS w4 158os 4 . Nw� 12.o <br /> - poYn LA, %5(06 <br />