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Date run 3/21/2016 2:07:51PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by (brown Pagel <br />Facility Information as of 3/21/2016 <br />Record Selection Criteria: Facility ID FA0017262 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0014103 <br />Owner Name <br />M&R ZOLEZZI <br />Owner DBA <br />M&R ZOLEZZI <br />Owner Address <br />17787 E FRONT ST <br />LINDEN, CA 95236 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />POBOX 39 <br />LINDEN, CA 95236 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0017262 10186169 <br />Facility Name M&R ZOLEZZI <br />Location 0 S COMSTOCK 1/4 MI EAST OF RD <br />LINDEN, CA 95236 <br />Phone 0 <br />Mailing Address POBOX 39 <br />LINDEN, CA 95236 <br />Care of <br />Location Code 99 - UNINCORPORATED a <br />BOS District 004 - WINN, CHARLES <br />APN 09109022 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0030144 <br />Mail Invoices to Owner <br />Account Name M&R ZOLEZZI <br />Account Balance as of 3/21/2016: $53.00 <br />Make changestcorrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />1 SSN/Fed Tax ID <br />New Owner ID : <br />ri2L .a,n I hftr <br />l 4'tK_ GfIr q5723 4a <br />t GyY AXL <br />t 323 � Q.leea' <br />Alt Phone <br />Fax <br />EMail : <br />Mail Invoices to: <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <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- -Farm Operations PR0525447 EE0002670 - MUNIAPPA NAIDU Active Y N A I D <br />40 - AST EXEMPT FAC < 1,320 GAL PRO529528 EE0000753 - WILLY NG Inactive Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0533235 Inactive Y N A I 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: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />EHD Staff: <br />COMMENTS: <br />Date / ! <br />' $25.00 = Amount Paid Date <br />Amount Paid Date <br />Received by <br />Date / / Account out: Date / 2Z/ <br />Invoice #: <br />r'4 <br />