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Date run 4/10/2018 1:44:04PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 4/10/2018 <br />Record Selection Criteria: Facility ID FA0017023 <br />OWNER FILE INFORMATION Number of facilities for this owner : 1 <br />Owner ID <br />OW0013864 <br />Owner Name <br />C&A NAVARRA RANCH INC <br />Owner DBA <br />C&A NAVARRA RANCH INC <br />OwnerAddress <br />475 W BLEWETT RD <br />TRACY, CA 953049326 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />475 W BLEWETT RD <br />TRACY, CA 953049326 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0017023 10185771 <br />Facility Name <br />C&A NAVARRA RANCH INC <br />Location <br />25000 S BIRD RD <br />TRACY, CA 95304 <br />Phone <br />209-836-0005 x0 <br />Mailing Address <br />475 W BLEWETT RD <br />TRACY, CA 953049326 <br />Care of <br />Location Code 99 - UNINCORPORATED A <br />BOS District 005 - ELLIOTT, BOB <br />APN 23911005 <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 AR0029905{� �c`\r% �6 New Account ID: <br />Mail Invoices to Owner -f'W" J � Mail Invoices to: Owner / Facility / Account <br />Account Name C&A NAVAR RANCH INC (Circle One) <br />Account Balance as of 4/10/2018: $ 08 0 <br />(Circle One) <br />Transferto Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1958 - HM -Farm Operations PR0525208 EE0002670 - MUNIAPPA NAIDU Active Y N A © D <br />2840 -AST EXEMPT FAC < 1,320 GAL PR0529307 EE0000753 - WILLY NG Inactive Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGI PR0533101 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, 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 will be performed in accordance with all applicable Ordinance Codes and/or 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 />CO ME TS: <br />JJ_ <br />Date <br />$25.00 = Amount Paid Date <br />Amount Paid Date <br />Received b <br />Date / / Account out: Date <br />Gl n q C rn"d <br />4\_L - t' -C , , PIr- tidje-tv <br />Invoice #: <br />