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Date run 10/11/2018 10:22:20/ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by DONNA Pagel <br />Facility Information as of 10/11/2018 <br />Record Selection Criteria: Facility ID FA0017368 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0014209 <br />Owner Name <br />TIM MCKINSEY <br />Owner DBA <br />TIM MCKINSEY <br />OwnerAddress <br />11991 HIDDEN GLEN CT <br />Phone <br />OAKDALE, CA 95361 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-996-3314 <br />Mailing Address <br />PO BOX 863 <br />Location Code <br />KNIGHTS FERRY, CA 95361 <br />Care of <br />004 - WINN, CHARLES <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0017368 10186341 <br />Facility Name <br />TIM MCKINSEY <br />Location <br />30545 E RIVER RD <br />ESCALON, CA 95320 <br />Phone <br />209-996-3314 x0 <br />Mailing Address <br />PO BOX 863 <br />KNIGHTS FERRY, CA 95361 <br />Care of <br />Tim mckinsey <br />Location Code <br />99 - UNINCORPORATED A <br />BOS District <br />004 - WINN, CHARLES <br />APN <br />24915041 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0030250 <br />Mail Invoices to Account <br />Account Name TIM MCKINSEY <br />Account Balance as of 10/11/2018: $101.00 <br />Program/Element and Description <br />Make changestcorrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />3asyS E, R)"yef Rcl <br />Estc,wn. CA 9S3,P!0 <br />3OS45" E. TZ,'vef Rc) <br />Escalo)i . CA SK -3;t0 <br />Alt Phone <br />Fax <br />EMail : <br />Record ID Employee ID and Name <br />New Account ID: <br />Mail Invoices to: Owner / <br />Status <br />Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />New Owner? Delete <br />1958 - HM -Farm Operations PR0525553 EE0002670 - MUNIAPPA NAIDU Active Y N A I D <br />2840 -AST EXEMPT FAC < 1,320 GAL PRO529811 EE0000753 - WILLY NG Inactive Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGI PR0531832 Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andtor project specific, PHS/EHD 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 and/or Standards and Slate and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />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 Re <br />EHD Staff: _ P�c� / f l Date �/ Lel l Account out: Date 1-31, <br />COMMENTS: <br />\ / IDVOICe #: <br />-6-4acwa..r 8,l$4V_-A < ►� Z�ocs n�-� have mo:►1 cec a p+o. e4e <br />/Os-" P cli ,e bx' v1c 6n 1 Irv✓ cdGlfes's� <br />