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Date run 1121/2015 1:40:26PR SAN JCOUIN COUNTY ENVIRONMENTAL HEAW DEPARTMENT Report#5021 <br /> Run by `��'''' Pagel <br /> Facility Information as of 1/21/2015 <br /> Record Selection Criteria: Facility ID FA0017216 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 SSN/Fed Tax ID <br /> Owner ID OW0014057 New Owner ID <br /> Owner Name CREEKSIDE FARMS <br /> Owner DBA CREEKSIDE FARMS <br /> Owner Address 8464 N DEMARTINI LN <br /> LINDEN, CA 95236 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 8464 N DEMARTINI LN <br /> LINDEN, CA 95236 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0017216 10186095 <br /> Facility Name CREEKSIDE FARMS <br /> Location 7997 ESCALON BELLOTA RD <br /> LINDEN, CA 95236 <br /> Phone 209-887-3319 x0 <br /> Mailing Address 8464 N DEMARTINI LN <br /> LINDEN, CA 95236 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 09308010 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0030098 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name CREEKSIDE FARMS (Circle One) <br /> Account Balance as of 112112015: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PR0525401 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2221 -USED OIL ONLY-<5 TONS/YR PR0538550 EE0009488-JEFFREY WONG Active Y N A (I N D <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0530235 EE0000753-WILLY NG Inactivr Y N A �' D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532340 Inactive Y N A I D <br /> RUING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned owner,operator or agent of same,acknowledge that all site,anSor project specific,PHSIEHD 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 withall applicable Ordinance Codes and/or Standards and State andlor <br /> Federal Laws, <br /> APPLICANT'S SIGNATURE: — Date —( 1 2 / / /–f,- <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Rec y <br /> REHS: Date 1 I Account out: Date _I.)-3 1 <br /> ---JPOMMENTS: <br />