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Date run 2/21/2013 3:00:32PN SAN JO <br />Run by <br />Record Selection Criteria: Facility ID FA0017046 <br />AN COUNTY ENVIRONMENTAL HEAI <br />Facility Information as of 2/21/2013 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0013887 <br />Owner Name <br />TEIXEIRA DAIRY <br />Owner DBA <br />TEIXEIRA DAIRY <br />Owner Address <br />2455 NAGLEE RD 406 <br />209-836-4081 x0 <br />TRACY, CA 95304 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />2455 NAGLEE RD <br />TRACY, CA 95304 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0017046 <br />Facility Name <br />TEIXEIRA DAIRY <br />Location <br />21150 MT HOUSE PKWY <br />TRACY, CA 95304 <br />Phone <br />209-836-4081 x0 <br />Mailing Address 2455 NAGLEE RD <br />TRACY, CA 95304 <br />Care of <br />Location Code <br />BOS District <br />APN 20915021 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />DEPARTMENT Report #5021 <br />Pagel <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) 0 L <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />Account ID AR0029928 A <br />Mail Invoices to Owner (tv <br />Account Name TEIXEIRA-QAI --I� <br />Account Balance as of 2/21/2013:66 000 <br />ProgranVElement and Description <br />Record ID Employee ID and Name <br />i`, A -rd L P`r. kt'.t''i <br />I ITALA Mom <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Status New Owner? Delete <br />—==HM -Farm Operations PR0525231 Y N A I D <br />• -226-- SM HW GEN <5 TONS/YR PR0530995 EE0002646 - THUY TRAN --Actives Y N A I D <br />4&M— AST FAC - SPCC EXEMPT PR0530994 EE0002646 - THUY TRAN cove Exempt Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCH,PR0533440 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 <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 and(or <br />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 Typer�! Check Number Recel e �Iy <br />REHS: ..li ! _ Date ! / Account out: _T Date / Z <br />CN-MENTSG4� "vr13 <br />