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Date run 10/9/2015 9:36:32AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 10/9/2015 <br />Record Selection Criteria: Facility ID FA0017440 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID <br />OW0014281 <br />Owner Name <br />KATHERINE KELLY <br />Owner DBA <br />KATHERINE KELLY <br />Owner Address <br />26565 COUNTY RD 97D <br />DAVIS, CA 95616 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />26565 COUNTY RD 97D <br />DAVIS, CA 95616 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0017440 10186453 <br />Facility Name KATHERINE KELLY <br />Location 3951 W SARGENT <br />LODI, CA 95240 <br />Phone 805-595-2646 x0 <br />Mailing Address 26565 COUNTY RD 97D <br />DAVIS, CA 95616 <br />Care of <br />Location Code 99 - UNINCORPORATED P <br />BOS District 004 - WINN, CHARLES <br />APN 02515025 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN/Fed Tax ID <br />New Owner ID <br />Alt Phone <br />Fax <br />EMail : <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0030322 New Account ID: <br />Mail Invoices to Owner % r 0 Mail Invoices to: Owner / Facility / Account <br />Account Name KATHERIN,.E"KELLY_ (/ (Circle One) <br />Account Balance as of 10/9/2015: $479.00 llllt11 <br />(Circle One) <br />f Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1958 - HM -Farm Operations PR0525625 EE0008709 - JAMIE DE LA ROSA Active Y N A <br />2220 - SM HW GEN <5 TONS/YR PR0529578 EE0001422 - ARIS VELOSO Active Y N <br />2840 - AST EXEMPT FAC < 1,320 GAL PR0529577 EE0001422 - ARIS VELOSO Inactive Y N A <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0531817 Inactive Y N A D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andror 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 andror Standards and State andror <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 />FHD Staff: nom% '`t7 <br />Date <br />* $25.00 = Amount Paid Date <br />Amount Paid Date <br />Received by <br />_ Date Account out: /;/� Date IP/_7 / <br />COMMENTS: <br />Invoice #: <br />