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Dale nm 1/31/2013 2:19:43PR SAN JC )UIN COUNTY ENVIRONMENTAL HEA `I DEPARTMENT Report#5021 <br /> Run by 1#0 Paget <br /> Facility Information as of 1/31/2013 <br /> Record Selection Criteria: Facility,10 FA0017152 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0013993 New Owner IO <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 FA0017152 <br /> Facility Name ,J PIAZZA FARMS INC <br /> Location 394 E ACAMPO RD �i4 I I _Y1tO_r D <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 /> BOIS District 004 -VOGEL, KEN Fax <br /> APN 01309021 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 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 1/31/2013: $0.00 <br /> (Circle One) <br /> Transfer to ActivelnacNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1 HM-Farm Operations PR0525337 Active Y N A I D <br /> 2840 ST EXEMPT FAC < 1,320 GAL PR0528976 EE0001422-ARTS CACAPIT Active,Exempt Y N A I D <br /> C-ELECTRONIC REPORTING STATE SURCH,PR0532506 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/EMD houdyoharges associated wit this fadlity <br /> or activity will be billed to the party identified as the OWNER on thisform l also certify tat all operations will be performed in accordance with all applicable Ordinance Codes andicr Standards and State andlor <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 Number Re! by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: 13 <br />