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Date run 5/2/2017 10:27:OOAM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 5/2/2017 <br />Record Selection Criteria: Facility ID FA0017345 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0014186 <br />Owner Name <br />C&W FARMS LLC <br />Owner DBA <br />C&W FARMS LLC <br />Owner Address <br />15799 S CARROLTON RD <br />ESCALON, CA 95320 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-604-8691 <br />Mailing Address <br />15799 S CARROLTON RD <br />ESCALON, CA 95320 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0017345 10186301 <br />Facility Name <br />C&W FARMS LLC <br />Location <br />15799 S CARROLTON RD <br />ESCALON, CA 95320 <br />Phone <br />209-838-7065 x0 <br />Mailing Address <br />15799 S CARROLTON RD <br />ESCALON, CA 95320 <br />Care of <br />RICHARD VAN VLIET <br />Location Code <br />BOS District <br />APN <br />20506038 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <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 />Account ID AR0030227 <br />Mail Invoices to Owner Mail Invoices to: <br />Account Name C&W FARMS LLC <br />Account Balance as of 5/2/2017: $0.00 <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? Delete <br />r \ <br />1958 - HM -Farm Operations PR0525530 EE0002670 - MUNIAPPA NAIDU Active Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0532095 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: ' $25.00 = <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />EHD Staff: Date 7 /, <br />COMMENTS: / <br />v <br />Date <br />Amount Paid Date <br />Amount Paid Date <br />Received by <br />Account out: Date <br />Invoice #: <br />