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Date run 3/14/2013 2:48:14K SAN JO- "'UIN COUNTY ENVIRONMENTAL HEA I DEPARTMENT Report 05021 <br /> Run by <br /> Facility Information as of 3/14/2013 Pagel <br /> Record Selection Criteria: Facility ID FA0017349 <br /> Make changestcorrections in RED ink. �� f� <br /> INFORMATION CHANGE(date) f <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0014190 New Owner ID <br /> Owner Name OHLAND FARMS <br /> Owner DBA OHLAND FARMS <br /> Owner Address 20865 RIVER RD <br /> RIPON, CA 95366 <br /> Home Phone Not Specified <br /> WorklBusiness Phone Not Specified <br /> Mailing Address 20865 RIVER RD <br /> RIPON, CA 95366 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CE RS ID FA0017349 10,186,307 <br /> Facility Name OHLAND FARMS <br /> Location 20865 RIVER RD <br /> RIPON, CA 95366 <br /> Phone 209-599-5331 x0 <br /> Mailing Address 20865 RIVER RD <br /> RIPON, CA 95366 <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 24523058 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 AR0030231 New Account ID: <br /> Mail Invoices to Owner Ji � Mail Invoices to: Owner / Facility / Account <br /> Account Name OHLAND S /� n u{l (Circle One) <br /> Account Balance as of 3/14/2013: 53.00 e. d� � S !L <br /> 3 j(� (Circle One) <br /> !! Transfer to Activeflnactve <br /> ProgramlFlement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PRO525534 Active Y N AD <br /> 2840-AST EXEMPT FAC < 1,320 GAL PRO529762 EE0000753-WILLY NG Active,Exempt Y N A i D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHoPRO532591 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSIFHD 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 land'1or Standards and State <br /> flanciforwr <br /> Federal Laws. /fir <br /> APPLICANT'S SIGNATURE:EJ: ` 1 f iJ T Date 1 <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date I 1 �T <br /> Payment TypeNumberReceiv <br /> REHS: Date 17y ! Account out: Date 1 � <br /> COMMENTS: <br /> 2�� � ILI <br />