Laserfiche WebLink
Date run 9/18/2015 10:34:42AI SAN JO IN COUNTY ENVIRONMENTAL HEALODEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9/18/2015 <br /> Record Selection Criteria: Facility ID FA0017530 <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 ID : <br /> Owner ID OW0014371 New Owner ID <br /> Owner Name KLM RANCH INC <br /> Owner DBA KLM RANCH INC <br /> Owner Address 8490 LAMBERT RD <br /> ELK GROVE, CA 95757 <br /> Home Phone Not Specified <br /> Work/Business Phone 916-684-2900 <br /> Mailing Address 8490 LAMBERT RD <br /> ELK GROVE, CA 95757 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017530 10186599 <br /> Facility Name KLM RANCH INC <br /> Location 5430 ONETO RD <br /> STOCKTON, CA 95212 <br /> Phone 916-505-9208 x0 <br /> Mailing Address 8490 LAMBERT RD <br /> ELK GROVE, CA 95757 <br /> care of KLM Ranches <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 004-WINN, CHARLES Fax <br /> APN 08704021 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 AR0030412 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name KLM RANCH INC (Circle One) <br /> Account Balance as of 9/18/2015: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Desorption Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PRO525715 EE0000006-HAZA SAEED Active Y N A 1 D <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0529499 EE0000753-WILLY NG Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534329 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,angor protect 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 with all applicable Ordinance Codes andror Standards and State ano/or <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: 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 Received by <br /> EHD Staff: Date ._j Account out: Date <br /> COMMENTS: <br /> Invoice#: <br /> �`Yd! Z333 <br />