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Date run 3/9/2015 9:39:07AM SAN JC UIN COUNTY ENVIRONMENTAL HEA I DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 3/9/2015 <br />Record Selection Criteria: Facility ID FA0017445 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID <br />OW0014286 <br />Owner Name <br />TRIPLE H FARMING <br />Owner DBA <br />TRIPLE H FARMING <br />Owner Address <br />15515 N PRESCOTT RD <br />NewOwner? <br />MANTECA, CA 95336 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-480-8130 <br />Mailing Address <br />15515 N PRESCOTT RD <br />PR9530543 EE0009001 - ELENA MANZO <br />MANTECA, CA 95336 <br />Care of <br />A Q D <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0017445 10186459 <br />Facility Name <br />TRIPLE H FARMING <br />Location <br />15515 N PRESCOTT RD <br />MANTECA, CA 95336 <br />Phone <br />209-480-8130 x0 <br />Mailing Address <br />15515 N PRESCOTT RD <br />MANTECA, CA 95336 <br />Care of <br />Jerry Haugg <br />Location Code <br />BOS District <br />APN <br />20805008 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0030327�� <br />Mail Invoices to Owner // <br />Account Name TRIPLE FIFARMI.NG�( <br />Account Balance as of 3/9/2015: $719.00 <br />Make changesicorrections 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 />/ <br />Transfer to <br />Activellnactve <br />ProgranVElement and Description <br />rordD Employee ID and Name <br />Status <br />NewOwner? <br />Delete <br />1958 - HM -Farm Operations <br />30 EE0002474 - MICHAEL PARISSI <br />Active <br />Y N <br />A I D <br />2830 - AST FAC - SPCC EXEMPT <br />PR9530543 EE0009001 - ELENA MANZO <br />Active <br />Y N <br />A Q D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG P 0533219 Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned o r, operator or agent of same, acknowledge that all site, andlor project speck, PHS✓EHD hourly charges associated with thisfacility <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 andlor <br />Federal Laws. <br />APPLICANT'S SIGNATURE: Q'v'f # e - <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />REHS: <br />COMMENTS: <br />* $25.00 = <br />Date <br />Date <br />Amount Paid Date -/-/ <br />_ Amount Paid Date <br />Received by <br />i <br />Account out: 14 Date /�/�� <br />