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Data run 2/17/2015 :55:43AR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Repod#5021 <br /> Run by Papel <br /> Facility Information as of 2/17/2015 <br /> Record Selection Criteria: Facility ID FA0005381 <br /> Make changesfcorrections 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 OW0004224 New Owner ID <br /> Owner Name J LOMBARDI FARMS <br /> Owner DBA J LOMBARDI FARMS <br /> Owner Address 16998 E GAWNE RD <br /> STOCKTON, CA 95215 <br /> Home Phone 209-649-0017 <br /> Work/Business Phone 209-948-1909 <br /> Mailing Address 16998 E GAWNE RD <br /> STOCKTON, CA 95215 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0005381 10181815 <br /> Facility Name J LOMBARDI FARMS <br /> Location 29665 KASSON RD <br /> TRACY, CA 95376 <br /> Phone 209-948-1964 - <br /> Mailing Address 16998 E GAWNE RD <br /> STOCKTON, CA 95215 Y) I/VYI 11471V r <br /> Care of <br /> Location Cade 99 - UNINCORPORATED,8 Aft Phone <br /> BOS District 005- ELLIOTT, BOB Fax <br /> APN 25527052 EMall: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0005843 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name J LOMBARDI FARMS (Circle One) <br /> Account Balance as of 2/17/2015: $292.00 <br /> (CmIe One) <br /> Program/Element and Description Record 10 Employee ID and Name �1`�-�\ S��s Tmnsferto ActiveMaclve <br /> 1, New Owner! mDelete <br /> 1958-HM-Fa O erations PR0525844 EE0002474- I Active Y N A D <br /> HW GEN<5 TONS/YR PR05292164 EE0009001 -ELE A MANZO Active Y N A D <br /> 2333- ITY-obsolete PR0502269 EE0000451 - Inactive Y N A0 <br /> 2830-AST FAC -SPCC EXEMPT PRO529363 EE0009001 -ELENA MANZO Active Y N A e D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO531371 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,endfor project specific,PHS(EHD hourly charges associated with this fatality <br /> or activity will be billed to the party Identified as the OWNER on this f'orm._I also certify that all operations will be performed In accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Laws, <br /> LM <br /> APPLICANTS SIGNATURE: Date / l—s /=S <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date_/� <br /> Payment Type Check Number —Received by, _ <br /> RENS: 1111 - NPYO-Z L Date, Account out: Date__�f / <br /> COMMENTS: <br /> to AI&I Lois . &u jl�"� <br />