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1 <br />Date run 2/8/2017 9:52:07AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 2/8/2017 <br />Record Selection Criteria: Facility ID FA0017476 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID <br />OW0014317 <br />Owner Name <br />JOHN KESZLER FARMS (LODI, CA) <br />Owner DBA <br />JOHN KESZLER FARMS <br />Owner Address <br />3861 E ARMSTRONG RD <br />LODI, CA 95240 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-334-3189 <br />Mailing Address <br />3861 E ARMSTRONG RD <br />Lodi, CA 95240 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0017476 10186499 <br />Facility Name JOHN KESZLER FARMS <br />Location 3861 E ARMSTRONG RD <br />LODI, CA 95240 <br />Phone 209-334-3189 x <br />Mailing Address <br />Care of Bruce Keszler <br />Location Code 99 - UNINCORPORATED P <br />BOS District 004 - WINN, CHARLES / <br />APN 05812013 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0030358 <br />Mail Invoices to Account <br />Account Name JOHN KESZLER FARMS <br />Account Balance as of 2/8/2017: $80.00 <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 />K0 S I E At- wag+rvn t2a <br />Alt Phone <br />Fax <br />EMail : <br />Mail Invoices to: <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1958 - HM -Farm Operations PR0525661 EE0002670 - MUNIAPPA NAIDU Active Y N A I D <br />2840 - AST EXEMPT FAC < 1,320 GAL PR0528990 EE0000030 - AARON HANG Inactive Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0531471 Inactive 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, PHSIEHD 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 andlor Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />EHD Staff: <br />COMMENTS: <br />* $25.00 = <br />Date <br />Date <br />Amount Paid Date <br />_ Amount Paid Date <br />Received by <br />Account out: Date -,I- <br />Invoice <br />Invoice #: <br />e.Jo;reSS c V%c�,,Se G,% ixev- reAvrh vv-A%k . <br />