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Date run 1/24/2012 10:47:53AI SAN JO UIN COUNTY ENVIRONMENTAL HEA [ DEPARTMENT Report#5021 <br /> Run by 5290 Pagel <br /> Facility Information as of 1/24/20 <br /> Record Selection Criteria: Facility ID FA0016994 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0013835 New Owner ID <br /> Owner Name D&L FARMS <br /> Owner DBA D&L FARMS <br /> Owner Address 18000 BACON ISLAND <br /> STOCKTON, CA 95219 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 355 <br /> HOLT, CA 95234 <br /> Care of <br /> FACILITY FILE INFORMATION rY <br /> Facility ID FA001 <br /> Facility Name FARMS <br /> Locati 18000 BACON ISLAND <br /> STOCKTON, CA 9521 <br /> Phone - - D <br /> Mailing Address PO BOX 355 r!g <br /> HOLT, CA 95234 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 003 - BESTOLARIDES Fax <br /> APN 12905014 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 AR0029876 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name D&L FARMS (Circle One) <br /> Account Balance as of 1/24/2012: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0529169 EE0004636-GARRETT BACKUS Active Y N A I D <br /> 2223-AGRICULTURAL HAZ MAT STORAGE FACILPRO525179 Active Y N A I D <br /> 2830'-JAST'RAC--SPCC EXEMPT fi RO z' 0:1 EE0004636-GARRETT BACKUS Active,Exempt Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPR0532899 Active 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 <br /> facility 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 Ordinace Codes and/or Standards and <br /> Stale and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date ! / <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 /> REHS: Date / / Account out: I/ Date t /,24-U /� <br /> COMMENTS: <br /> \\eh-env\envi s ion\reports\5021.rpt <br />