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. . . . . . . . . . . . . . . . . . . . . <br />Date run 2/29/2012 4:24:55PM SAN JC JUIN COUNTY ENVfRONMENTALHEi,- _'H DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 2/29/2012 <br />Record Selection Criteria: Facility ID FA0017247 <br />Make changes/corrections in RED ink <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION SSN / Fed Tax ID <br />Owner ID OW001 4088 New Owner ID <br />Owner Name J&J FARMING LLC -- <br />Owner DBA J&J -FARMING LLC <br />Owner Address 10549 N JACK TONE RD <br />STOCKTON, CA 95212 <br />Home Phone Not-Specified7 Ll <br />Work/Business Phone Not Specified <br />Mailing Address 10549 N JACK TONE RD <br />STOCKTON, CA 95212 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID FA0017247 <br />Facility Name J&J FARMING LLC <br />Location 10549 N JACK TONE RD <br />STOCKTON, CA 95212 <br />Phone 209-931-1391 <br />Mailing Address 10549 N JACK TONE RD <br />STOCKTON, CA 95212 <br />Care of <br />Location Code 99 - UNINCORPORATED Alt Phone <br />BOS District 004 - VOGEL, KEN Fax <br />APN 06321023 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 AR0030129 New Account ID: <br />Mail Invoices to Owner Mail Invoices to: Owner Facility Account <br />Account Name J&J FARMING LLC '!5 -a' uc t \L (Circle One) <br />Account Balance as of 2/29/2012: $280.00 <br />(Circle One) <br />Transfer to Activelinactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />2220 - SM HW GEN <5 TONSIYR PR0530346 EE0001422 - ARIS CACAPIT Active Y N A I D <br />2223 -AG CULTURAL HAZ MAT STORAGE FACILIPRO525432 Active Y N A I D <br />EE0001422 - ARIS CACAPIT Active,Exempt Y N A I D <br />4740 - WASTE TIRE SITE - EXEMPT PR0535718 EE0007379 - AMANDA BOERTIEN Inactive Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHPR0531561 Active Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this <br />facility 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 Ordinate Codes and/or Standards and <br />State and/or Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />REHS: <br />COMMENTS <br />\\eh-env\envision\reDorts\5021.rot <br />* $25.00 = <br />Date <br />Date <br />Amount Paid Date <br />Amount Paid Date <br />Received by <br />Account out: -t'�'Ot Date <br />12za� -6- A �, <br />