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Date run 3/11/2016 4:35:49PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 3/11/2016 <br />Record Selection Criteria: Facility ID FA0017153 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0013994 <br />Owner Name <br />GILL FAMILY LTD PARTNERSHIP <br />Owner DBA <br />GILL FAMILY LTD PARTNERSHIP <br />Owner Address <br />11465 N HAM LN <br />LODI, CA 95242 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />PO BOX 8250 <br />STOCKTON, CA 95208 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0017153 10185979 <br />Facility Name GILL FAMILY LTD PARTNERSHIP <br />Location 11465 N HAM LN <br />LODI, CA 95242 <br />Phone 209-603-0286 x0 <br />Mailing Address PO BOX 8250 <br />STOCKTON, CA 95208 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />1 SSN/Fed Tax ID <br />New Owner ID : <br />Fd 30i- 1 <br />t o l ?52-41 <br />Care of <br />Location Code Alt Phone <br />BOS District Fax <br />APN 05907004 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 AR0030035 New Account ID: <br />Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br />Account Name GILL FAMILY LTD PARTNERSHIP (Circle One) <br />Account Balance as of 3/11/2016: $0.00 <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 PR0525338 EE0002670 - MUNIAPPA NAIDU Active Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PRO533666 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 ancVor Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: 5e,55, k-�"; , Date <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 />Amount Paid _ <br />Amount Paid <br />Date -/-/ <br />Date <br />Received <br />Date / / Account out: L4=Date 3 / <br />Invoice #: <br />(/� jje-� ��A J /; N a <br />