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Date run 12/11/2017 4:43:13P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/11/2017 <br /> Record Selection Criteria: Facility ID FA0024387 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number sof facilities for this owner: 1 SSM 1 Fed Tax ID <br /> Owner ID OW0022951 New Owner ID <br /> Owner Name MARK LUCCHESI <br /> Owner DBA <br /> Owner Address 16261 E RIVER RD <br /> RIPON, CA 95366 <br /> Home Phone Not Specified <br /> WorklBusiness Phone Not Specified <br /> Mailing Address 16261 E RIVER RD <br /> RIPON, CA 95366 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0024387 _ <br /> Facility Name LUCCA WINERY <br /> Location 16261 E RIVER RD <br /> RIPON, CA 95366 <br /> Phone <br /> Mailing Address 16261 E RIVER RD <br /> RIPON, CA 95366 <br /> Care of <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 004-WINN, CHARLES Fax <br /> APN 24519017 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 AR0045440 New Account ID: _ <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility I Account <br /> Account Name LUCCA WINERY (Circle One) <br /> Account Balance as of 1211112017: $0.00 <br /> (Circle One) <br /> Transfer to Aclivellnactve <br /> ProgramfElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 9 4�. BP-Regular-Primary Locati4R Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all sita,andlor 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 Godes andlor Standards and State andfor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE Date 1 1 <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Received by <br /> EHD Staff: Date 1 1 Account out: Date l 1 <br /> COMMENTS: <br /> Invoice#: <br />