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Date run 2/12/2015 1:41:44Ph SAN JC UIN COUNTY ENVIRONMENTAL HEA ` DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 2/12/2015 <br />Record Selection Criteria: Facility ID FA0017192 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN /Fed Tax ID <br />Owner ID OW0014033 New Owner ID <br />Owner Name VAN DIEMEN FARMS <br />Owner DBA VAN DIEMEN FARMS <br />Owner Address 20361 N RAY RD <br />LODI, CA 95242 <br />Home Phone Not Specified <br />Work/Business Phone 209-986-9113 <br />Mailing Address 20361 N RAY RD <br />LODI, CA 95242 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0017192 10186051 <br />Facility Name VAN DIEMEN FARMS <br />Location 20361 N RAY RD <br />LODI, CA 95242 <br />Phone 209-368-3690 x0 UU <br />Mailing Address 20361 N RAY RD <br />LODI, CA 95242 <br />Care of Edward Van Diemen <br />Location Code Alt Phone <br />BOS District Fax <br />APN 01117007 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 AR0030074 New Account ID: <br />Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br />Account Name VAN DIEMEN FARMS (Circle One) <br />Account Balance as of 2/12/2015: $292.00 <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 PR0525377 EE0008709 - JAMIE DE LA ROSA Active Y N A I D <br />2220 - SM HW GEN <5 TONS/YR PR0530400 EE0001422 - ARIS VELOSO Active Y N A _A-� D <br />2830 - AST FAC - SPCC EXEMPT PR0530399 EE0001422 - ARIS VELOSO Active Y N pC_L.-� D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PRO533448 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 i ntified a the OW fy th <br />Ron this rm. I also certiat all Aerations will be a ormed in a ordanwith ce all applicable Ordinance Codes andror Standards and State ndlor Federal Laws. <br />�2� wd—4 %� �-j`� iS LII 320 �. <br />APPLICANT'S SIGRFATURE: Date / 1 <br />Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Type Aq Ieck Number Received b <br />RENS: Date / / Account out: L16 Date <br />I <br />COMMENTS: <br />