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Date run 2/13/2015 1J:42:10AI SAN JC AN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 2/13/2015 <br />Record Selection Criteria: Facility ID FA0017562 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0014403 <br />Owner Name <br />MOHR ENTERPRISES LLP <br />Owner DBA <br />MOHR-FRY RANCHES <br />Owner Address <br />12609 N WEST LN <br />Active <br />LODI, CA 95240 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-334-3808 <br />Mailing Address <br />12609 N WEST LN <br />A D <br />LODI, CA 95240 <br />Care of <br />A D <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0017562 10186639 <br />Facility Name RANCH 40 <br />Location 12609 N WEST LN <br />LODI, CA 95240 <br />Phone 209-334-3808 x <br />Mailing Address 12609 N WEST LN <br />LODI, CA 95240 <br />Care of MOHR-FRY RANCHES <br />Location Code <br />BOS District <br />APN 05810015 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Make changes/corrections in RED ink. �+ n <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 />Account ID AR0030444 <br />Mail Invoices to Account Mail Invoices to: <br />Account Name MOHR-FRY RANCHES p I� <br />Account Balance as of 2/13/2015: $292.002 <br />Program/Element and Description / Record ID Employee ID and Name <br />1958 - HM -Farm Operations PR0525747 EE0008709 - JAMIE DE LA ROSA <br />2220 - SM HW GEN <5 TONS/YR PR0530582 EE0001422 - ARIS VELOSO <br />2830 - AST FAC - SPCC EXEMPT PR0530581 EE0001422 - ARIS VELOSO <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0531849 <br />New Account ID: : <br />Owner / Facility / <br />(Circle One) <br />Account <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 or <br />be billed the party identified as the OWNER o s form.,I also rtify that all operations w''ll``b�� performed in accordance v/ith all applicable Ordinance C des and/ornd <br />Staards and State andor Federal Laws <br />ell ic�lr <br />APPLICANT'S SIGNATURE: Date / / P*_ <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />REHS: <br />COMMENTS: <br />* $25.00 = Amount Paid _ <br />Amount Paid <br />Date Z / I ---> /I� Account out: <br />Date / / d uS <br />Date <br />Recei a by <br />Date <br />d <br />(Circle One) <br />Transfer to <br />Active/Inactve <br />Status <br />New Owner? <br />Delete <br />Active <br />Y N <br />A I D <br />Active <br />Y N <br />A I D <br />Active <br />Y N <br />A D <br />Inactive <br />Y N <br />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 or <br />be billed the party identified as the OWNER o s form.,I also rtify that all operations w''ll``b�� performed in accordance v/ith all applicable Ordinance C des and/ornd <br />Staards and State andor Federal Laws <br />ell ic�lr <br />APPLICANT'S SIGNATURE: Date / / P*_ <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />REHS: <br />COMMENTS: <br />* $25.00 = Amount Paid _ <br />Amount Paid <br />Date Z / I ---> /I� Account out: <br />Date / / d uS <br />Date <br />Recei a by <br />Date <br />d <br />