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Dater n 1/15/2015 3:49:04PA SAN JO, JIN COUNTY ENVIRONMENTAL HEA' I DEPARTMENT Report 95021 <br /> Run Facility Information as of 1/15/2015 Pagel <br /> Record Selection Criteria: Facility ID FA0022749 <br /> Make changes/corrections 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 PD <br /> Owner ID OW0020544 New Owner ID <br /> Owner Name Bernard Tevelde <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 559-583-1277 <br /> Mailing Address 13866 4th Ave <br /> Hanford, CA 93230 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022749 10484881 <br /> Facility Name B&R Tevelde Ranch <br /> Location 17000 Lower Jones Rd <br /> Stockton, CA 95206 <br /> Rhone 209-481-3641 x <br /> Mailing Address PO BOX 5 <br /> Holt, CA 95234 <br /> Care of B&R Tevelde Ranch <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 129-170-13 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0041690 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility 1 Account <br /> Account Name Richard Marcucci (Circle one) <br /> Account Balance as of 111512015: $0.00 <br /> (Circle One) <br /> Transfer to Acliveflnactue <br /> PrograrnlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PRO539765 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2220-SM HW GEN{5 TONS/YR PRO539764 EE0001421 -STACY RIVERA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMrNT: I,the undersigned owner.operator or agent of same,acknowledge that all site,anti project specific,PHS/i 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 ani <br /> Federal taws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date ! I <br /> Water System to be TRANSFERED: Amount Paid Date ! I <br /> Payment Type Check Number Received by <br /> REHS: Date 1 I Account out-. Y Date j 1 <br /> COMMENTS: <br />