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Date run 3/9/2016 8:50:37AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 3/9/2016 <br />Record Selection Criteria: Facility ID FA0017194 <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 OW0014035 New Owner ID <br />Owner Name VOLKERT VINEYARDS <br />Owner DBA VOLKERT VINEYARDS <br />Owner Address 1002 W HARNEY LN <br />LODI, CA 95242 <br />Home Phone Not Specified <br />Work/Business Phone 209-608-9879 <br />Mailing Address 3414 HORSEHEAD BAY DR <br />GIG HARBOR, WA 98335-5840 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0017194 10186055 <br />Facility Name VOLKERT VINEYARDS <br />Location 1002 W HARNEY LN <br />LODI, CA 95240 <br />Phone 209-608-9879 x0 <br />Mailing Address 3414 HORSEHEAD BAY DR t <br />GIG HARBOR, WA 98335-5840 <br />Care of <br />Location Code 99 - UNINCORPORATED P Alt Phone <br />BOS District 004 - WINN, CHARLES Fax <br />APN 05806014 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 AR0030076 New Account ID: <br />Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br />Account Name VOLKERT 2VY-ARDJ(Circle One) <br />Account Balance as of 3/9/2016: $ 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 PR0525379 EE0002670 - MUNIAPPA NAIDU Active Y N AD <br />2840 - AST EXEMPT FAC < 1,320 GAL PR0529272 EE0000753 - WILLY NG Inactive Y N A D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0534636 Inactive Y N A 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 withal[ applicable Ordinance Codes and/or Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: Tom" �UDate <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 />EHD Staff: P" I /\J+ /' I� Date Account out: iii Date <br />COMMENTS: <br />Invoice #: <br />