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Date run 2/20£2014 10:42:12AI SAN JOIN COUNTY ENVIRONMENTAL HEAI•DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 2/20/2014 <br /> Record Selection Criteria: FacilityID FA0017128 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner lD OW0013969 New Owner ID <br /> Owner Name BATES FARMS <br /> Owner DBA BATES FARMS <br /> Owner Address 21200 N DAVIS RD <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 1227 <br /> WOODBRIDGE, CA 95258 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0017128 10,185,937 <br /> Facility Name BATES FARMS <br /> Location 21200 N DAVIS RD <br /> LODI, CA 95240 <br /> Phone 209-649-4030 x0 <br /> Mailing Address PO BOX 1227 <br /> WOODBRIDGE, CA 95258 <br /> Care of <br /> Location Code Alt Phone <br /> BOIS District Fax <br /> APN 01309033 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> Y <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0030010 (r Ar� NewAccount ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility 1 Account <br /> Account Name BATES FARMS, (S (Circle One) <br /> Account Balance as of 2/20/2014: $53.00)' 2 V' <br /> (Circle One) <br /> Transfer to Active/Inacive <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner' Delete <br /> 1958-HM-Farm Operations PRO525313 Active Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0531074 EE0000753-WILLY NG Active,l Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO534033 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of some,acknowledge that ell site,anc for project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also rectify that all operations will be performed in accordance with all applicable Ordinance Codes and'or Standards and State ander <br /> Federal Laws, <br /> APPLICANT'S SIGNATURE: y �.r "� 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 <br /> RENS: Date_9, Account out: Date_/ <br /> COMMENTS: <br /> r <br /> � r <br />