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Date run 6/18/2013 11:22:54AI SAN Run by Record Selection Criteria: Facility ID kQUIN COUNTY ENVIRONMENTAL H_ ,TH DEPARTMENT Facility Information as of 6/18/2013 jUN 18 2013 OWNER FILE INFORMATION NVIRONMENT HEALTH Owner ID OW0002489 0[)MVP%02448 Owner Name Location 23335 E DODDS RD Owner DBA FRANK BORMA—tItefi& OwnerAddress 23335 E DODDS RD _ ESCALON, CA 95320 Home Phone Not Specified Work/Business Phone 209-838-1648 Mailing Address 23335 E DODDS RD ESCALON, CA 95320 Care of APN 20716004 FACILITY FILE INFORMATION Make changes/correctlons In RED Ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) Report #5021 Pagel SSN /Fed Tax ID w riwn.r In - ,? aIla Facility ID / CERS ID FA0003365 10,181,115 Facility Name Pf Location 23335 E DODDS RD _el, ESCALON, CA 95320 Phone 209-838-7737 _ Mailing Address 23335 E DODDS RD ESCALON, CA 95320 Care of Location Code 99 - UNINCORPORATED P BOS District 004 - VOGEL, KEN F APN 20716004 _ E _ w, EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title �__—A—'� �r� Day Phone 209-838-7737 — — Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0002942 Mail Invoices to Facility Account Name BORBA, FRANK V & SONS 39-347 Account Balance as of 6/18/2013: $0.00 (Circle One) Transfer to Active/lnactve Program/Element and Description Reoord ID Employee ID and Name Status Now Owner? Delete 1958 - HM -Farm Operations PRO525785 Active Y N A I D 2011 -GRADE A DAIRY PR0200060 EE0004589 - KADEANNE LINHARES Inactive Y N A I D 2220 - SM HW GEN <5 TONS/YR PRO530160 EE0001421 - STACY RIVERA Active Y N A I D 2775 - EMPLOYEE HOUSING -DAIRY EXEMPTION PRO515042 EE0002089 - OMRAN SOOD Active Y N A I D 2830 - AST FAC - SPCC EXEMPT PRO530159 EE0001421 - STACY RIVERA Active,l Y N A i D ERSC - ELECTRONIC REPORTING STATE SURCHARG PRO533190 Inactive Y N A I D 4617 - EMPLOYEE HOUSING -WATER SUPPLY WA0515738 EE0004589 - KADEANNE LINHARES Active Y N BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of tame, acknowledge that all site. andlor project specific, PHS/EHD hourly charges associated with this facility or activity will be billed to the party Idenlfied as the OWNER on this form I also certify that all operations will be performed In accordance with all applicable Ordinance Codes and'or Standards and Slate and'or Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: ` $25.00 = Amount Paid Date / I Water System to be TRANSFERED: Amount Paid Date ! ! Payment Type Check Number Recei e y REHS: Date ! % l ! Account out: Date l l COMMENTS: