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[RftoMd <br /> run 5;161r2o <br /> 13 4:07:23PM SAN JC�UIN COUNTY ENVIRONMENTAL HEA�i DEPARTMENT by Report#5041 <br /> Facility Information as of 5/6/2013Page' <br /> Selectioeda: Facility ID FA0017152 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> Owner ID OW0013993 SSN/Fed Tax IDNew Owner l0 <br /> Owner Name J PIAZZA FARMS INC <br /> Owner DBA J PIAZZA FARMS INC <br /> Owner Address 711 CROSS ST <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 711 CROSS ST <br /> LODI, CA 95242 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID if CERS ID FA0017152 10,185,977 <br /> Facility Name J PIAZZA FARMS INC <br /> Location 341 E ACAMPO RD <br /> LODI, CA 95240 <br /> Phone 209-368-0765 x0 <br /> Mailing Address 711 CROSS ST <br /> LODI. CA 95242 <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 01309021 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0030034 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name J PIAZZA FARMS INC (Circle One) <br /> Account Balance as of 5/6/2013: $53.00 <br /> (Circle One) <br /> Transferto Activallnactve <br /> Prograry Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PR0525337 Active Y N A D <br /> 2840-AST EXEMPT FAC <1,320 GAL PRO528976 EE0001422-ARIS CACAPIT Active,Exempt Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PRO532506 Inactive Y N A 1 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS/EHD hourly charges associated with thisfacility <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 andor Standards and State andor <br /> Federal Laws. <br /> APPLICANTS 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 NumberRece,�ive�d�/b(��y <br /> REHS: Date / / Account out: sir— Date I & <br /> COMMENTS: e-1 ✓,�� lip CA— /� 1� <br /> (�u - <br /> 51-� l <br />