Laserfiche WebLink
Daterun 2111/2013 10:32:18AI SAN J( IUIN COUNTY ENVIRONMENTAL HEA N DEPARTMENT Report#5021 <br /> rum by \/ Pagel <br /> Facility Information as of 2/11/2013 <br /> Record Selection Criteria: Facility ID FA0016778 <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 OW0013619 New Owner ID <br /> Owner Name MICHELETOS FARM <br /> Owner DBA MICHELETOS FARM <br /> Owner Address 483 N AUSTIN RD <br /> MANTECA, CA 95336 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 483 N AUSTIN RD <br /> MANTECA, CA 95336 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0016778 <br /> Facility Name MICHELETOS FARM <br /> Location 629 N AUSTIN RD <br /> MANTECA, CA 95336 <br /> Phone 209-823-6117 x0 <br /> Mailing Address 483 N AUSTIN RD <br /> MANTECA, CA 95336 <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOB District 005 -ORNELLAS, LEROY Fax <br /> APN 20821028 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 AR0029660 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name MICHELETOS FARM (Circle One) <br /> Account Balance as of 2/11/2013: $0.00 <br /> (Circle One) <br /> Transfer to ActiveAnscive <br /> PrograndElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> i HHM-Farm Operations PR0524963 Active Y N A I D <br /> ( MOc ST EXEMPT FAC < 1,320 GAL PR0529144 EE0000753-WILLY NG Active,Exempt Y N A D <br /> , i <br /> ELECTRONIC REPORTING STATE SURCH,PR0532694 Inactive Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of some,acknowledge that all site,andor project specigc,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 ander Standards and State ander <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 Received by z <br /> REHS: Date_/ / Account out: —1 16 Date_ / <br /> COMMENTS: <br /> V <br />