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FAIL I Date run 2/14/2017 3:04:07PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 95021 Run by Pagel Facility Information as of 2/14/2017 Record Selection Criteria: Facility ID FA0017153 OWNER FILE INFORMATION Number of facilities for this owner Owner ID OW0013994 Owner Name GILL FAMILY LTD PARTNERSHIP Owner DBA GILL FAMILY LTD PARTNERSHIP Owner Address 11465 N HAM LN LODI, CA 95242 Home Phone Not Specified Work/Business Phone Not Specified Mailing Address -P4)-B49iF'$--9150 95208 Care of FACILITY FILE INFORMATION Facility ID / CERS ID FA0017153 10185979 Facility Name GILL FAMILY LTD PARTNERSHIP Location 11465 N HAM LN LODI, CA 95242 Phone 209-603-0286 x0 Mailing Address PO BOX 1450 LODI, CA 95241 Care of Location Code BOS District APN 05907004 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID � hx ly5 L V ck% c A q l- t L -i .s: c7 Alt Phone Fax EMail : Account ID AR0030035 Mail Invoices to Owner Mail Invoices to: Account Name GILL FAMILY LTD PARTNERSHIP Account Balance as of 2/14/2017: $80.00 New Account ID: : Owner / Facility / Account (Circle One) (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1958 - HM -Farm Operations PR0525338 EE0002670 - MUNIAPPA NAIDU Active Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0533666 Inactive Y N A I D 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 or+ 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 Federal Laws. APPLICANT'S SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number EHD Staff: COMMENTS: Date " $25.00 = Amount Paid Date Amount Paid Date Received by Date / / Account out: G- Date Invoice #: