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Date run 8/17/2018 2:13:52PK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 8/17/2018 <br />Record Selection Criteria: Facility ID FA0024800 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID OW0023430 <br />Owner Name Robert and Alfreda Andrews Family Trust <br />Owner DBA <br />Owner Address <br />Home Phone Not Specified <br />Work/Business Phone 650-326-8226 <br />Mailing Address 76 .lames <br />Atherton, CA 94027 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID/ CERS ID FA0024800 10753378 <br />Facility Name RANCH 60 <br />Location 2000 W Peltier Rd <br />Lodi, CA 95242 <br />Phone 209-334-3808 x <br />Mailing Address 12609 N. West Lane <br />Lodi, CA 95240 <br />Care of Mohr -Fry Ranches <br />Location Code <br />BOS District <br />APN 013-07-03 <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 AR0046429 New Account ID: : <br />Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br />Account Name Mohr -Fry Ranches (Circle One) <br />Account B lance as of 8/17/2018: $296.00 <br />(Circle One) <br />f Transfer to Active/Inactve <br />�Pr�,gra ! le and Description Record ID Employee ID and Name Status New OwneR Delete <br />19VVVVvv211 - HMBP-Reqular-Primary Location PR0543649 EE0008709 - JAMIE LIMA Active Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT I, the undersigned owner, operator or agent of same, acknowledge that all site, anctor 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 ancl/or Standards and State ancVor <br />Federal Laws. <br />APPLICANT'S SIGNATURE: Date <br />Program Records to be TRANSFERED: ` $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Type Check Number R 4 F I Received b <br />EHD Staff: , Date / / Account out: Date 7// / <br />COMMENTS: 2 <br />Invoice #: <br />Q <br />