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Date run 7/30/2014 2:37:42PN SAN JC TJIN COUNTY ENVIRONMENTAL HEAL 'DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 7/30/2014 <br />Record Selection Criteria: Facility ID FA0017032 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0013873 <br />Owner Name <br />LARRY PELLEGRI FARMS <br />Owner DBA <br />LARRY PELLEGRI FARMS <br />Owner Address <br />1710 HILLSIDE RD <br />Phone <br />SANTA BARBARA, CA 93101-4020 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />1710 HILLSIDE RD <br />SANTA BARBARA, CA 93101-4020 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0017032 10185787 <br />Facility Name <br />LARRY PELLEGRI FARMS <br />Location <br />6588 W JACOBS RD <br />STOCKTON, CA 95206 <br />Phone <br />209-463-7079 <br />Mailing Address <br />1710 HILLSIDE RD <br />SANTA BARBARA, CA 93101-4020 <br />Care of <br />Location Code 99 - UNINCORPORATED p <br />Bos District 005 - ELLIOTT, BOB <br />APN 13124004 <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 />Mail Invoices to Owner <br />Account Name LARRY PELLEGRI FARMS <br />Account Balance as of 7/30/2014: $0.00 <br />1 <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 />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 - HM -Farm Operations PR0525217 Active Y N ADI <br />D <br />2220 - SM HW GEN <5 TONS/YR PR0530935 EE0001421 - STACY RIVERA Active Y N AD <br />2830 - AST FAC - SPCC EXEMPT PR0530934 EE0001421 - STACY RIVERA Active,I Y N AD <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PRO532020 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 with all applicable Ordinance Codes and/or Standards and State and/or <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 Recely d <br />REHS: Date // Account out: Date <br />COMMENTS: /%✓�YL�— �N- �'_ Ga/� <br />_+'a/'Z 7" <br />Tl <br />