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Date md' 1/29/2014 10:07:58A1 SAN J IN COUNTY ENVIRONMENTAL HEA DEPARTMENT <br />Report #5021 <br />Run by �F Pagel <br />Facility Information as of 1/29/2014 <br />Record Selection Criteria: Facility ID FA0017064 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0013905 <br />Owner Name <br />YAMASAKI FARMS <br />Owner DBA <br />YAMASAKI FARMS <br />Owner Address <br />1435 COOLIDGE AVE <br />TRACY, CA 95376 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />1435 COOLIDGE AVE <br />TRACY, CA 95376 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility lD/CERS ID FA0017064 10185835 <br />Facility Name YAMASAKI FARMS <br />Location 144 E DURHAM FERRY RD <br />TRACY, CA 95304 <br />Phone 209-835-1575 x0 <br />Mailing Address 1435 COOLIDGE AVE <br />TRACY, CA 95376 <br />Care of <br />Location Code 99 - UNINCORPORATED P <br />BOB District 005 - ELLIOTT, BOB <br />APN 25520001 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0029946 <br />Mail Invoices to Owner <br />Account Name YAMASAKI FARMS <br />Account Balance as of 1/29/2014: $0.00 <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 />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 />Transfer to Active/Inaclve <br />PmgranvElement and Description Record ID Employee ID and Name Status New Owner? Delete <br />1958 -HM -Farm Operations PRO525249 Active Y N A I D <br />2830 -AST FAC - SPCC EXEMPT PRO529366 EE0009001 - ELENA MANZO Active,l Y N A I D <br />ERSC- ELECTRONIC REPORTING STATE SURCHARG PR0634156 Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andfor project speai5e, 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 cartify that all operations will be performed In accordance with all applicable Ordinance Codes anNor Standards and State anwor <br />Federal Laws. <br />APPLICANTS SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Ta eck Number Race' ed by <br />REHS: Ft . �I^a Date / / IC4 Account out: <br />COMMENTS: <br />Aep P1� 222 I. <br />