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FRunby <br /> a` 3;2/2015 8:26:a8AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Report 85021 <br /> Facility Information as of 3/2/2015 Pagel <br /> RecoM Selection Cnteria: Facility ID FA0017154 <br /> Make changes/corrections in RED ink. ��11 <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID : L(0 00 7 2/ 4 Y <br /> Owner ID OW0013995 New Owner ID <br /> Owner Name JEM RANCH INC <br /> Owner DBA JEM RANCH INC <br /> Owner Address 2951 W SARGENT RD <br /> LODI, CA 95242 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 2951 W SARGENT RD <br /> LODI, CA 95242 <br /> Care of -- <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017154 10185981 2 <br /> Facility Name JEM RANCH INC C . <br /> Location 2951 W SARGENT RD <br /> LODI, CA 95242 <br /> Phone 209-369-1640 x0 <br /> Mailing Address 2951 W SARGENT RD 1 -70 gtto N: DFi II/Ai9S 1ZD <br /> LODI, CA 95242 L 4) Or <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone Ze7q) 32.7 -5Y3 <br /> BOS District 004 -WINN. CHARLES Fax ay) N09 y.l <br /> APN 02516023 Entail: 3/ & yh~ •Com <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name pererz C D STA HA G,e7A <br /> Title 7 <br /> Day Phone S7LIF9/ ]j 2— —/ yU'J <br /> Night Phone 20 y 3'1.7 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0030036 New Account ID: <br /> Mail Invoices to Aeaner FAC i I. 1 Ty IV/I M E Mail Invoices to: Owner / Facility / Account <br /> Account Name JEM RANCH INC (Circe 0") <br /> Account Balance as of 3/2/2015: $79.00 <br /> Garcia One) <br /> Transterto ActiveMacNe <br /> Prtprem/Elemant and Description Record ID Employee ID anti Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PR0525339 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PR0529575 EE0001422-ARTS VELOSO Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533150 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the un fersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSrEHO hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. l also candy that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Laws, <br /> APPLICANTS SIGNATURE: �� `-� l/ 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: dvl — ��^Tt�'L�- Date_/�/ /� Account out: _1 Date <br /> COMMENTS: <br />