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�EpARTMENT Report#5021 <br /> i. Date run 2/19/2014 10:22:55AI SAN JO. IN COUNTY ENVIRONMENTAL HEAL. _ Pagel <br /> Run by Facility Information as of 2/19/2014 <br /> Record Selection Criteria: Facility ID FA0017402 - <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0014243 New Owner ID <br /> Owner Name CHARLES S COX FARMS <br /> Owner DBA CHARLES S COX FARMS <br /> Owner Address 0 HWY 33 AT HWY 132 <br /> VERNALIS, CA 95385 <br /> Home Phone Not Specified <br /> WorklBusiness Phone Not Specified <br /> j Mailing Address PO BOX 1381 <br /> PATTERSON, CA 95363 <br /> f Care of <br /> 1 <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0017402 10,186,399 <br /> Facility Name CHARLES S COX FARMS <br /> Location 0 HWY 33 AT HWY 132 <br /> VERNALIS, CA 95385 <br /> Phone -209-894-3741 x0 <br /> Mailing Address PO BOX 1381 <br /> PATTERSON, CA 95363 <br /> Care of <br /> Location Code Alt Phone <br /> r BOS District Fax <br /> APN 25519001 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 AR0030284 New Account ID: <br /> Mail Invoices to Owner r Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name CHARL OX FARNJ (circle One) <br /> Account Balance as of 2/19/2014C!5-7— /2 U� <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program0ement and Description Record ID Employee ID and Name' Status New Owner? Delete <br /> 1 1958-HM-Farm Operations PR0525587 Active Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL­ PR0530992 EE0000753-WILLY NG Active,I Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO533305 Inactive Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: t,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specific,PHSlEHD-hourly charges associated with this faci€ity' <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 andlor standards and state andfor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: r�Ci. �Ce,,1/I Ste— Date / 1 <br /> Program Records to be TRANSFERED: "$25.00 Amount Paid Date 1 ! <br /> Water System to be TRANSFERED: Amount Paid Date / 1 <br /> Payment Ty fhfe.ck__Number ' Recety d�¢y <br /> REHS: �� !I"'� Date _ Account out: _ _ Date l�1 <br /> COMMENTS: ' <br />