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Date run 2/27/2015 9:55:02AN SAN JUIN COUNTY ENVIRONMENTAL HEAW DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/27/2015 <br /> Record Selection Criteria: Facility ID FA0017431 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0014272 New Owner ID <br /> Owner Name LIEN'S POULTRY& EGG FARM <br /> Owner DBA LIEN'S POULTRY& EGG FARM <br /> Owner Address 30636 E CARTER RD <br /> FARMINGTON, CA 95230 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 663 <br /> CERES, CA 95307 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017431 10186443 <br /> Facility Name LIENS POULTRY& EGG FARM <br /> Location 30636 E CARTER RD <br /> FARMINGTON, CA 95230 <br /> Phone 209-996-4659 x0 <br /> Mailing Address PO BOX 663 <br /> CERES, CA 95307 <br /> Care of <br /> Location Code %PhoneBOS District <br /> APN 20708004 E <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0030313 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name LIEN'S POULTRY& EGG FARM (Circle One) <br /> Account Balance as of 2/27/2015: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PR0525616 EE0008709-JAMIE DE LA ROSA Inactive Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PR0531079 EE0001421 -STACY RIVERA Active,l Y N A (2�) D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD 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 and/or Standards and State and/or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: 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 b <br /> REHS: ,J-.A- /' ��z` Date_�/ 21/ �j Account out: Date / 3 / S <br /> COMMENTS: <br /> �� a J ew," Ae*j 0.� P, 4�rt44ri <br />