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Date run 1/2014 3:58:42PR SAN J( UIN COUNTY ENVIRONMENTAL HEA [ DEPARTMENT Report #5021 <br />Pagel <br />Run by 1273 Facility Information as of 2/11/2014 <br />Record Selection Criteria: Facility ID FA0017032 <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 Recei J` <br />REHS: n Date / / Account out: Date / i / ! �T <br />COMMENTS: <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION <br />SSN/Fed Tax ID <br />Owner ID OW0013873 <br />New Owner ID <br />Owner Name LARRY PELLEGRI FARMS <br />Owner DBA LARRY PELLEGRI FARMS <br />Owner Address 2307 CALHOUN WAY <br />STOCKTON, CA 952073306 <br />Home Phone Not Specified <br />Work/Business Phone Not Specified <br />Mailing Address 2307 CALHOUN WAY <br />LL I <br />STOCKTON, CA 952073306 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID/CERS ID FA0017032 10,185,787 <br />Facility Name LARRY PELLEGRI FARMS <br />Location 6588 W JACOBS RD <br />STOCKTON, CA 95206 <br />Phone 209-463-7079 x0 <br />Mailing Address 2307 CALHOUN WAY <br />ld LL51 1]� <br />STOCKTON, CA 952073306 <br />_ DPS <br />Care of <br />Location Code 99 - UNINCORPORATED P <br />Alt Phone <br />BOS District 005 - ELLIOTT, BOB <br />Fax <br />APN 13124004 <br />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 AR0029914 <br />New Account ID: <br />Mail Invoices to Owner <br />Mail Invoices to: Owner / Facility / <br />Account <br />Account Name LARRY PELLEGRI FARMS <br />(Circle One) <br />Account Balance as of 2/11/2014: $266.00 <br />(Circle One) <br />Transfer to <br />Active/Inactve <br />Program/Element and Description Record ID <br />Employee ID and Name Status New Owner? <br />Delete <br />1958 - HM -Farm Operations PR0525217 <br />Active Y N <br />A I D <br />2220 - SM HW GEN <5 TONS/YR PR0530935 <br />EE0001421 -STACY RIVERA Active Y N <br />A I D <br />2830 - AST FAC - SPCC EXEMPT PRO530934 <br />EE0001421 - STACY RIVERA Active,l Y N <br />A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0532020 <br />Inactive Y N <br />A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent <br />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 andror <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />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 Recei J` <br />REHS: n Date / / Account out: Date / i / ! �T <br />COMMENTS: <br />