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Date run 12/3012015 1:56:03F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Pagel <br /> Run by <br /> Facility Information as of 12/3012015 <br /> Record Selection Criteria: Facility ID FA0023260 <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 1 Fed Tax ID <br /> Owner ID OW0021427 New Owner ID <br /> Owner Name Greg Gerlomes <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> WorklBusiness Phone 209_931-2718 <br /> Mailing Address 11502 East Eight Mile Road <br /> Stockton, CA 95212 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility 1D!CERS ID FA0023260 10653994 <br /> Facility Name Greg Gerlomes (Girolami Farms) <br /> Location 8112 N Fine Rd <br /> Linden, CA 95236 <br /> Phone 209-931-2718 x <br /> Mailing Address 11502 East Eight Mile Road <br /> Stockton, CA 95212 <br /> Care of Greg Gerlomes <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN EMaiI: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0042793 New Account ID: <br /> Mail Invoices to Account Mail Involces to: Owner 1 Facility 1 Account <br /> Account Name Greg Gerlomes (Circle one) <br /> Account Balance as of 1213012015: $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 PRO540658 EE0002670-MUNIAPPA NAIDU Active Y N A 1 D <br /> 2220-SMV HW GEN 45 TONS/YR PRO540657 EE0000027-CINDY VO Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specific,PHSlEHD hourly charges associated with this facilely <br /> or activity will be billed to the party identified as the ii on this form. I also certify that all operations wiR be performed in accordance with all applicable Ordinance Codes andlor Standards and State andror <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I f <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date I 1 <br /> Water System to be TRANSFFRFD: Amount Paid Date ! ! <br /> Payment Type Check Number Received b <br /> EHD Staff: 4ll/f` Date a-/ -40 / i4 Account out: Date 15 <br /> COMMENTS: <br /> Invoice#: <br />