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Date run 2/8/2017 8:11:27AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 2/8/2017 Record Selection Criteria: Facility ID FA0017445 OWNER FILE INFORMATION Number of facilities for this owner 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 FACILITY FILE INFORMATION Facility ID / CERS ID FA0017445 10186459 Facility Name TRIPLE H FARMING Location 15515 N PRESCOTT RD MANTECA, CA 95336 Phone 209-629-9293 x Mailing Address Jjl�TRra--^,,T-Tri ' Care of Jerry Haugg Location Code BOS District APN 20805008 EMERGENCY NOTIFICATION Contact Name CONTACT INFORMATION Title Day Phone / Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0030327 Mail Invoices to Account Account Name TRIPLE Fl FARMING Account Balance as of 2/8/2017: $80.00 Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN /Fed Tax ID New Owner ID : Q Alt Phone Fax EMail : Mail Invoices to 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 PR0525630 EE0002670 - MUNIAPPA NAIDU Active Y N A I D 2830 - AST FAC - SPCC EXEMPT PR0530543 EE0009001 - ELENA MANZO Inactive Y N A I 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 ill 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 andor Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERF_D: Payment Type Check Number EHD Staff: COMMENTS ' $25.00 = Date Date Amount Paid Date -/-/ _ Amount Paid Date Received by Account out: Date Invoice #: