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Date run 3/20/2015 12:04:52PI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report*5021 <br /> Run by Papel <br /> Facility Information as of 3/20/2015 <br /> Record Selection Criteria: Facility ID FA0017545 <br /> Make changeslcorrections 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 OW0014386 New Owner ID <br /> Owner Name LAGORIO BROS FARMS <br /> Owner DBA LAGORIO BROS FARMS <br /> Owner Address 20001 E FLOOD RD <br /> LINDEN, CA 95236 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-887-2141 <br /> Mailing Address 20001 E FLOOD RD <br /> LINDEN, CA 95236 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERSID FA0017545 10186625 <br /> Facility Name LAGORIO BROS FARMS <br /> Location 19108 E TOBACCO RD <br /> LINDEN, <br /> Phone 7-2141 XO r7 <br /> MaiCS <br /> s 18600 Tobacco Road IILJLGLC ICJLINDEN, CA 95236of BrettLagono 111 DLoe Alt Phone <br /> Fax D D D aLGt',p <br /> APN 10514003 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 AR0030427 New Account I <br /> Mail Invoices to Account Mail Invoices to: Owner / acilit Account <br /> Account Name LAGORIO BROS FARMS circ naj <br /> Account Balance as of 3/20/2015: $0.00 <br /> (Circle One) <br /> Transfer to Aclivednacive <br /> Progranv Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PR0525730 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2220-SM HW GEN<5 TONSNR PR0530611 EE0009488-JEFFREY WONG Active Y N A 1 D <br /> 2830-AST FAC -SPCC EXEMPT PRO530610 EE0009488-JEFFREY WONG Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO533141 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSIEHD hourly charges associated"In this facility <br /> or activity will toe billed to the Party identifed as the OWNER on this forth. I else certify that all operations will ba Performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: 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: Date Account out: IA Date�/J�/—Z-J�7 <br /> COMMENTS: <br />