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Dale run 2111/2014 9:07:10AR SAN UIN COUNTY ENVIRONMENTAL HEW I DEPARTMENT Report#5021 <br />Run by 1273 Paget <br />Facility Information as of 2/11/2014 <br />I Record Selection Cdleda: Facility ID FA0017025 I <br />OWNER FILE INFORMATION <br />owner ID <br />OW0013866 <br />Owner Name <br />C&G FARMS <br />owner DBA <br />C&G FARMS <br />Owner Address <br />3458 W LINNE RD <br />TRACY, CA 95304 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />3458 W LINNE RD <br />TRACY, CA 95304 -$C6-q 1-5 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility lD/CERS ID <br />FA0017025 10,185,775 <br />Facility Name <br />C&G FARMS <br />Location <br />1777 W LINNE RD <br />TRACY, CA 95304 <br />Phone <br />209-835-2412 XO <br />Mailing Address <br />3458 W LINNE RD <br />TRACY. CA 95304-`'bc6` 3 <br />Care of <br />Location Code 99 - UNINCORPORATED P <br />BOS District 005 - ELLIOTT, BOB <br />APN 23922010 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0029907 <br />Mail Invoices to Owner <br />Account Name C&G FARMS <br />Account Balance as of 2/11/2014: $266.00 <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 />1277 1.//vuF_ <br />77 7 G l NNF_ <br />Alt Phone <br />Fax <br />EMail : <br />Program/Element and Description Record 10 Employee ID and Name <br />Mail Invoices to: <br />New Account ID: <br />Owner / Facility / Account <br />(Circle One) <br />(Circe One) <br />Transferto AcbviumacNe <br />Status New Owner? Delete <br />1958- HM -Farm Operations PRO525210 Active Y- N A I D <br />2220 - SM HW GEN <5 TONS/YR PR0529361 EE0009001 - ELENA MANZO - Active Y N A I D <br />2830 - AST FAC - SPCC EXEMPT PR0529360 EE0009001 - ELENA MANZO Active,l Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0534634 Inactivr Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, anNor project specific, 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 certify that all operations will be performed in accordance with all applicable Ordinance Codes andror Standards and State and'or <br />Federal Laws. <br />APPLICANT'S 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 Type Check Number Racal <br />RENS: Date Account out: Date <br />COMMENTS: <br />