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Date run 2/26/2015 4;17:55PR SAN JO IIN COUNTY ENVIRONMENTAL HEA. DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 2/26/2015 <br />Record Selection Criteria: Facility ID FA0017179 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0014020 <br />Owner Name <br />ROBERT BISHOFBERGER <br />Owner DBA <br />ROBERT BISHOFBERGER <br />Owner Address <br />4154 W TURNER RD <br />LODI, CA 95242 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-327-6526 <br />Mailing Address <br />4154 W TURNER RD <br />LODI, CA 95242 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0017179 10186025 <br />Facility Name ROBERT BISHOFBERGER <br />Location 4154 W TURNER RD <br />LODI, CA 95242 <br />Phone 209-368-3726 x0 <br />Mailing Address 4154 W TURNER RD <br />LODI, CA 95242 <br />Care of Robert Bishofberger <br />Location Code <br />BOS District <br />APN 02515023 <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. i <br />INFORMATION CHANGE (date) -2L , <br />OWNERSHIP CHANGE (date) <br />SSN/Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />Account ID AR0030061 New Account ID: : <br />Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br />Account Name ROBERT BIS BER (Circle One) <br />Account Balance as of 2/26/2015: $ 00 <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description RAecord ID Employee ID and Name Status New Owner? Delete <br />1958 - HM -Farm Operations PR0525364 EE0008709 - JAMIE DE LA ROSA Active Y N A 1 D <br />2830 - AST FAC - SPCC EXEMPT PR0530447 EE0001422 - ARIS VELOSO Active Y N A 01 D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0532638 Inactive 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 or <br />be billed to the party identifie is the 0Joisorm. I als rtify that all operations will be performed in accordance with all a - plicable Ordinance Codes and/or Standards and State and/or Federal Laws. <br />APPLICANT'S SIGNASIE: Ite <br />Program Records to be TRANSFERED: * $25.00 = Amount PaidWater System to be TRANSFERED: Amount Paid ae <br />Payment Type A <br />\ C eck Number Received <br />REHS: \ Date Account out: Date <br />COMMENTS: <br />