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Date run 5/22/2017 3:40:42PI\ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 5/22/2017 <br />Record Selection Criteria: Facility ID FA0017176 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0014017 <br />Owner Name <br />RAYMOND LIPPERT <br />Owner DBA <br />RAYMOND LIPPERT <br />Owner Address <br />1044 E ACAMPO RD <br />ACAMPO, CA 95220 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-333-0429 <br />Mailing Address <br />1044 E ACAMPO RD <br />ACAMPO, CA 95220 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0017176 10186021 <br />Facility Name RAYMOND LIPPERT <br />Location 1044 E ACAMPO RD <br />ACAMPO, CA 95220 <br />Phone 209-333-0429 x0 <br />Mailing Address 1044 E ACAMPO RD <br />ACAMPO, CA 95220 <br />Care of Raymond Lippert <br />Location Code 99 - UNINCORPORATED A <br />Bos District 004 - WINN, CHARLES <br />APN 01312006 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN/Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />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 AR0030058 New Account ID: <br />Mail Invoices to Account Mail Invoices to: <br />Owner / <br />Facility / Account <br />Account Name RAYMOND LIPPERT <br />(Circle One) <br />Account Balance as of 5/22/2017: $0.00 <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name <br />Status <br />New Owner? Delete <br />1958 - HM -Farm Operations PR0525361 EE0002670 - MUNIAPPA NAIDU <br />Active <br />Y N A C��b <br />2840 - AST EXEMPT FAC < 1,320 GAL PR0528947 EE0000030 - AARON HANG <br />Inactive <br />Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0533165 <br />Inactive <br />Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT. I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges <br />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 <br />Ordinance Codes and/or <br />Standards and State and/or <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 b <br />EHD Staff: Date -!!5-_124_l1i Account out: -1 <br />Date <br />COMMENTS: I ^ <br />I /� <br />Invoice #: <br />I L) (� � rN(� rte../ 1► P �, o..� � /r <br />c— ( �L <br />e> e-,7�..- <br />'-,-c7 L4 4-, <br />F -e 1" vr14--� o.— <br />i <br />�� 5 G��S 57,,b--4 <br />