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Daterun 3/7/2017 2:08:07PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 3/7/2017 Paget <br /> Record Selection 7dtena: Facility ID FA0017222 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> <br /> � <br /> Owner ID OW0014063 New Owner ID <br /> Owner Name DEMARTINI &GERLOMES <br /> Owner DBA DEMARTINI & GERLOMES <br /> Owner Address 8440 N DEMARTINI LN <br /> LINDEN, CA 95236 L: <br /> Home Phone Not Specified <br /> Work/Business Phone 209-887-3319 _ <br /> Mailing Address PO BOX 56 ,-]� N ) <br /> LINDEN, CA 95236 Li <br /> Care of <br /> Facility ID/CERS ID FA0017222 10186105 -- — - - <br /> Facility Name DEMARTINI &GERLOMES oy.� ��_ <br /> Location 8440 N DEMARTINI LN <br /> LINDEN, CA 95236 <br /> Phone 209-887-3319 x <br /> Mailing Address PO BOX 56 W, IQ <br /> LINDEN, CA 95236 <br /> Care of George Gerlomes <br /> Location Code 99- UNINCORPORATED P Alt Phone - <br /> BOS District 004-WINN, CHARLES Fax 11 <br /> APN 06524001 EMaff: L__A t� �• Q(y t �(, I.CO <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION !! <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0030104 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name DEMARTINI &GERLOMES (Circle one) <br /> Account Balance as of 3/7/2017: $306.00 <br /> (Circle One) <br /> PrograMElement and Des gia onRecord ID Employee ID and Name Status Transfer to ActiveMactve <br /> New Owner? Delete <br /> 1958-HM-Farm Operations PR0525407 EE0002670-MUNIAPPA NAIDU Active Y N D <br /> 2220-SM HW GEN<5 TONS/YR PR0529534 EE0001421 -STACY RIVERA Active N D <br /> 2830-AST FAC -SPCC EXEMPT PR0529533 EE0000030-AARON HANG Inactive N $9 D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532392 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific.PHS/EHD hourly charges associated with this facility <br /> or activity,will be billed to the party identifed 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 ander <br /> Federal Laws. <br /> APPLICANTS SIGNATURE:,/ � Date 3 /-'X1 /- 1'7 <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date / / <br /> Water System to be TRANSFERED: Amount Paid 3 0.6 Date 3_/�,� <br /> Payment Type Check Number o2,rooZ Received by <br /> EHD Staff: 4s— Date / Account out: _ <br /> COMMENTS: <br /> Invoice#: <br />