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Date iln 2/13/2017 3:02:38PA SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />i/ Facility Information as of 2/13/2017 <br />Record Selection Criteria: Facility ID FA0017336 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0014177 <br />Owner Name <br />HAROLD SANTOS <br />Owner DBA <br />HAROLD SANTOS <br />Owner Address <br />19788 E HWY 120 <br />ESCALON, CA 95320 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />19788 E HWY 120 <br />ESCALON, CA 95320 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0017336 10186289 <br />Facility Name HAROLD SANTOS <br />Location 19788 E HWY 120 <br />ESCALON, CA 95320 <br />Phone 209-838-8279 x0 <br />Mailing Address 19788 E HWY 120 <br />ESCALON, CA 95320 <br />Care of <br />Location Code <br />BOS District <br />APN 24508001 <br />Make changestcorrections 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 AR0030218 <br />Mail Invoices to Owner Mail Invoices to: <br />Account Name HAROLD SA OS— <br />Account Balance as of 2/13/2017: $8 .00 <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? <br />1958 - HM -Farm Operations PR0525521 EE0002670 - MUNIAPPA NAIDU Active Y N A�`D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0532945 Inactive Y N A <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 />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 />EHDStaff: Date Z / 2-4 Accountout: Date / /17 <br />COMMENTS: <br />Invoice #: <br />