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Report#5021 <br /> Date run 3/14/2011 9:37:12AA SAN:TOAD"TIN COUNTY ENVIRONMENTA•L'IIEALT R DEPARTMENT Paget <br /> Run by 5290 _.„, Facility InforMation as of 31141201'" - iI <br /> Record Selection Criteria: Facility ID FA0017146 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN 1 Fed Tax ID <br /> Owner ID OW0013987 New Owner ID <br /> Owner Name FISCHER FARM <br /> Owner DSA FISCHER FARM <br /> Owner Address 1120 S SCHOOL ST <br /> LODI, CA 95240570.7 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 1120 S SCHOOL ST <br /> LODI, CA 952405707 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> 4 Facility ID FA0017146 <br /> I. Facility Name FISCHER FARM <br /> Location 1890 W SARGENT RD <br /> LODI, CA 95242 <br /> Phone 209-333-7102 x0 <br /> Mailing Address 1120 S SCHOOL ST <br /> LODI, CA 952405707 <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> SOS District 004-VOGEL, KEN Fax <br /> APN 02517008 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 AR0030028 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner ! •Facility / Account <br /> f Account Name FISCHER FARM (Circle One) <br /> Account Balance as of 3/14/2011: $0.00 <br /> (Circle One) <br /> Transfer to ActiveMnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> = 2223-AGRICULTURAL HAZ MAT STORAGE FACILPRO525331 Inactive Y N A D <br /> 2840-AST EXEMPT FAC < 1,320 GAL PR0529573 EE0000753-WILLY NG Active,Exempt Y N 'A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPR0533351 Inactive <br /> 71 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSIEHD hourly charges associated with this <br /> facility 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 Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date ! / <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date I 1 <br /> Water System to be TRANSFERED: Amount Paid_ Date / 1 <br /> Payment Type Check Number --Received <br /> REHS: Date I 1 Account out: =_T Date <br /> COMMENTS: <br /> I , <br /> i <br /> 11eh-envlenvisionlreports15021_rpt a <br />