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Bate run 4/28/2016 10:59:40AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Rao°"awzl <br /> Run by Pagel <br /> Facility Information as of 4/28/2016 <br /> Record Selection Criers: Facility to FA0017289 <br /> Make changes/corrections 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 OW0014130 New Owner ID <br /> Owner Name YOCUM RANCH <br /> Owner DBA YOCUM RANCH <br /> Owner Address 9955 N SHELTON RD <br /> LINDEN, CA 95236 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 674 <br /> LINDEN, CA 95236 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017289 10186219 <br /> Facility Name YOCUM RANCH <br /> Location 9955 N SHELTON RD <br /> LINDEN, CA 95236 <br /> Phone 209-887-3504 x0 <br /> Mailing Address PO BOX 674 <br /> LINDEN, CA 95236 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 09346011 Eli <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0030171 New Account ID: <br /> Mail Invoices to OW Mail Invoices to: Owner / Facility / Account <br /> Account Name YOCU CH (Circle One) <br /> Account Balance as of 4/28/201 : $ <br /> (Circle One) <br /> Transfer to Activennai <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner! Delete <br /> 1958-HM-Farm Operations PR0525474 EE0002670-MUNIAPPA NAIDU Active Y N A (DID <br /> 2830-AST FAC -SPCC EXEMPT PR0530283 EE0001422-ARTS VELOSO Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533910 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSrEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also canny that all operations will be performed in accordance with all applicable Ordinance Codes angor Standards and State andii <br /> Federal Laws. ,, ,(', , 1 <br /> APPLICANTS SIGNATURE: T�I� rh'\ .1I?' P� Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date / /_ <br /> Payment Type Check Number Receive <br /> EHD Staff: M " Nom ^ Date 4 / 2$/ Account out: Date <br /> COMMENTS: <br /> IRVOICQ#: <br /> %r✓v1A��P 1?� �c�,,,�—u (��'� ..� ,�zf.., �.,n.,�,, � �..t� od,.fY,'_� G-�av� <br /> 1 GI l 9 ( C- TO, <br /> foe Geo 2 r l l eM ole Z Y C 1r a c.TW <br />