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Daterun ".5/16/2012 4:16:07PN SAN JOS` IN COUNTY ENVIRONMENTAL HEAL' ')EPARTMENT Report#5021 <br /> Rua by Pagel <br /> Facility Information as of 5/16/201 <br /> Record Selection Criteria: Facility ID FA0018149 <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 OW0014892 New Owner ID <br /> Owner Name DEL TERRA FARMS LLC <br /> Owner DBA DEL TERRA FARMS LLC <br /> Owner Address 33600 S KOSTER RD 4 4 C C _r: it c i I;l <br /> TRACY, CA 95304 I % •c %./� 1 I ? <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified (L1-`)j ;y <br /> Mailing Address 33600 S KOSTER RD /{(C U, = i } />.(, r 1✓ /U.Z <br /> TRACY, CA 95304 � - 5 3 7 <br /> Care of / <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0018149 <br /> Facility Name DEL TERRA FARMS LLC <br /> Location 33600 S KOSTER RD <br /> TRACY, CA 95304 <br /> Phone 209835-2-7-$�x0 1--r-a L2.< 7.2 el- 7-7 <br /> Mailing Address 33600 S KOSTER RD ��(�ID Q4-,,«- <br /> TRACY, CA 95304 2U <br /> Care of l <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 25516023 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION ¢� <br /> Contact Name r, y ( JLi I-VI �}AC C`-e <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0031919 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name DEL TERRA FARMS LLC (Circle one) <br /> Account Balance as of 5/16/2012: $0.00 <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 PR0526792 Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0530975 EE0002670-MUNIAPPA NAIDU Active Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PR0530974 EE0002670-MUNIAPPA NAIDU Active,Exempt Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PRO531394 Active 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 with all applicable Ordinance Codes and/or Standards and State andror <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Yl.f r r: ,. .r i., i. �, t t c/:. /l 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 Received by <br /> REHS: l i / ?- Date I Z" ! / 0 I I L Account out: Date �-Z ! l`1 ! 12— <br /> COMMENTS: <br /> —COMMENTS: �� ��� ��I '� I <br />