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Date run 211712015 11:49:30AI SAN JC UIN COUNTY ENVIRONMENTAL HEA- I DEPARTMENT Report#5021 <br /> Run by Now' 'me Pagel <br /> Facility Information as of 2/17/2015 <br /> Record Selection Criteria: Facility ID FA0017131 <br /> Make changes/corrections in RED ink. -711 <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 OW0013972 New Owner ID <br /> Owner Name EHLERS FAMILY FARMS <br /> Owner DBA EHLERS FAMILY FARMS <br /> Owner Address 530 S MILLS AVE <br /> LODI, CA 95242 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-334-5911 <br /> Mailing Address PO BOX 2239 <br /> LODI, CA 95241 <br /> Care of EHLERS, STEVEN K <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017131 10185943 <br /> Facility Name EHLERS FAMILY FARMS <br /> Location 15248 HWY 12 <br /> ISLETON, CA 95641 <br /> Phone 209-334-5911 <br /> Mailing Address PO BOX 2239 <br /> LODI, CA 95241 <br /> Care of EHLERS, STEVEN K <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 06903035 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 AR0030013 New Account ID: <br /> Mail Invoices to Owner <br /> CIA <br /> J� Mail Invoices to: Owner / Facility I Account <br /> Account Name EHLE Y FARMS (Circle One) <br /> Account Balance as of 2/17/201 $292.00 J lel/ <br /> {I W <br /> � (Circle One) <br /> Transfer to Activellnactve <br /> PregrarNElement and Description Record ID oyee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PRO525316 Active Y N AD <br /> 2220-SM HW GEN<5 TONSIYR PR0530584 EE0001422-ARIS VELOSO Active Y N A D <br /> 2830-AST FAC -SPCC EXEMPT PR0530583 FE0001422-ARIS VELOSO Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO533691 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same.,acknowledge that all site,ancl/or project specific,PHSfFHD 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 ancYer Standards and State andlor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 / <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date 1 f <br /> Water System to be TRANSFERED: Amount Paid Date 1 I <br /> Payment a Check Number Received by _ <br /> RENS: �� �f Date I l 1 Account out: L46 Date tel / <br /> C ENTS: <br /> Qy(e�/JL,.� a cru-- 1 e'-�'56, 2 = 2v 2 00 , <br /> TJJ���4rill ori rr^ 44 ,>�G,'( ��''�-f • Sol L e�. +�z <br /> �lU� 4,5 S . <br />