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Date run 7/30/2015 11:49:59AI SAN JO IIN COUNTY ENVIRONMENTAL HEAT DEPARTMENT Report#5021 <br />Run by - Pagel <br />Facility Information as of 7/30/2015 <br />Record Selection Criteria: Facility ID FA0017395 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0014236 <br />Owner Name <br />DASILVA DAIRY <br />Owner DBA <br />DASILVA DAIRY <br />Owner Address <br />16880 S HENRY RD <br />ESCALON, CA 95320 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />16877 HENRY RD <br />ESCALON, CA 953209426 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0017395 10186387 <br />Facility Name DASILVA DAIRY <br />Location 16551 S HENRY RD <br />ESCALON, CA 95320 <br />Phone 209-838-1121 <br />Mailing Address 16877 HENRY RD <br />ESCALON, CA 953209426 <br />Care of <br />Location Code 99 - UNINCORPORATED A <br />BOS District 004 - WINN, CHARLES <br />APN 22916033 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Ll <br />WIIZ IA+ - - lea L (r/c. iL/ ) <br />S� d <br />Alt Phone <br />Fax <br />EMail : <br />3 <br />�r A <br />ACCOUNTS RECEIVABLE FILE INFORMATION &/3 / ;2-a4 <br />Account ID AR0030277 rt&CJt Fy.� -� a- Qi , New Account ID: <br />Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br />Account Name DASILVA DAIRY (Circle0ne) <br />Account Balance as of 7/30/2015: $787.00�� (Circle One) <br />Transfer to <br />Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1958 - HM -Farm Operations PR0525580 EE0002474 - MICHAEL PARISSI Active Y N AI D <br />2220 - SM HW GEN <5 TONS/YR PR0529954 EE0002670 - MUNIAPPA NAIDU Inactive Y N A D <br />2830 - AST FAC - SPCC EXEMPT PR0529953 EE0009001 - ELENA MANZO Active Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0532762 Inactive Y N A D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andlor 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 />APPLICANT'S SIGNATURE: V Date 7_/ 36 ,L <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 />EHD Staff: t/✓) WA4-c-Date _ 7 >— Account out: Date <br />COMMENTS: <br />Invoice #: <br />0/1'1i< -fo a-dj v5'1-0 "/res ,,,_ C - <br />