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Date run 3/10/2017 5:38:15PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 3/10/2017 Record Selection Criteria: Facility ID FA0017445 OWNER FILE INFORMATION Number of facilities for this owner : 1 Owner ID OW0014286 Owner Name TRIPLE H FARMING Owner DBA TRIPLE H FARMING Owner Address 15515 N PRESCOTT RD Phone MANTECA, CA 95336 Home Phone Not Specified Work/Business Phone 209-629-9293 Mailing Address 15515 N PRESCOTT RD Location Code MANTECA, CA 95336 Care of A D FACILITY FILE INFORMATION Facility ID / CERS ID FA0017445 10186459 Facility Name TRIPLE H FARMING Location 15515 N PRESCOTT RD Transfer to MANTECA, CA 95336 Phone 209-629-9293 x Mailing Address PO BOX 867 1958 - HM -Farm Operations PR0525630 EE0002670 - MUNIAPPA NAIDU RIPON, CA 95366-0867 Care of Jerry Haugg Location Code Inactive BOS District A D APN 20805008 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, Title charges associated with this facility Day Phone Federal Laws. Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0030327 Mail Invoices to Account Account Name TRIPLE H FARMING Account Balance as of 3/10/2017: $80.00 Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN /Fed Tax ID New Owner ID yl , 1 Vr 6 < < Alt Phone Fax EMail : Mail Invoices to: New Account ID: : Owner / Facility / Account (Circle One) APPLICANT'S SIGNATURE: !� L.y� GIYI-✓� Date Program Records to be TRANSFERED: ` $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Received by EHD Staff: %l/t — 1%A41 '7- Date _/�/� Account out: Date 3 / / /-7 COMMENTS: cc,x ) v 2�rw v Invoice #: (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? lite 1958 - HM -Farm Operations PR0525630 EE0002670 - MUNIAPPA NAIDU Active Y N A I D 2830 - AST FAC - SPCC EXEMPT PR0530543 EE0000032 - JOHN ALANIZ Inactive Y N A D ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0533219 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 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 andfor Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: !� L.y� GIYI-✓� Date Program Records to be TRANSFERED: ` $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Received by EHD Staff: %l/t — 1%A41 '7- Date _/�/� Account out: Date 3 / / /-7 COMMENTS: cc,x ) v 2�rw v Invoice #: