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Date run 3/7/2016 12:47:12PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 3/7/2016 <br />Record Selection Criteria: Facility ID FA0016917 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0013758 <br />Owner Name <br />JACK VAN LEWEN <br />Owner DBA <br />JACK VAN LEWEN <br />Owner Address <br />21411 WAGNER RD <br />Inactive Y N A Q D <br />RIPON, CA 95366 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />21411 WAGNER RD <br />Ordinance Codes and/or Standards and State and/or <br />RIPON, CA 95366 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0016917 10185615 <br />Facility Name JACK VAN LEWEN <br />Location 21411 WAGNER RD <br />RIPON, CA 95366 <br />Phone 209-599-2742 x0 <br />Mailing Address 21411 WAGNER RD <br />RIPON, CA 95366 <br />Care of <br />Location Code 99 - UNINCORPORATED P <br />Bos District 004 - WINN, CHARLES <br />APN 24521026 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0029799 <br />Mail Invoices to Owner <br />Account Name JACK VAN LEWEN <br />Account Balance as of 3/7/2016: $53.00 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />1 SSN /Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID <br />Employee ID and Name <br />Status New Owner? Delete <br />1958 - HM -Farm Operations PR0525102 <br />EE0002670 - MUNIAPPA NAIDU <br />Active Y N A D <br />2840 - AST EXEMPT FAC < 1,320 GAL PR0529973 <br />EE0000753 - WILLY NG <br />Inactive Y N A Q D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0533706 <br />Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent <br />of same, acknowledge that all site, and/or 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 <br />will be performed in accordance with all applicable <br />Ordinance Codes and/or Standards and State and/or <br />Federal Laws. <br />n <br />/ <br />APPLICANT'S SIGNATURE: i 1A <br />— Date <br />Program Records to be TRANSFERED: " $25.00 = <br />Amount Paid Date <br />! / <br />Water System to be TRANSFERED: <br />Amount Paid Date <br />Payment Type heck Number <br />Receive <br />,C. <br />EHD Staff: �r7 Date l <br />7 / l� Account out: <br />Date J� <br />COMMENTS: <br />Invoice #: <br />