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Date run 4/25/2016 10:44:02AI SAN JOIN COUNTY ENVIRONMENTAL HEALIWEPARTMENT Repod#5021 <br /> Run by - Pagei <br /> Facility Information as of 4/25/2016 <br /> Record Selection Criteria: Facility ID FA0003662 <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: 2 SSN/Fed Tax ID <br /> Owner ID OW0002732 New Owner ID <br /> Owner Name A&W FARMS <br /> Owner DBA A&W FARMS <br /> OwnerAddress 12965 S MANTHEY RD <br /> LATHROP, CA 95330 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-993-6869 <br /> Mailing Address 12965 S MANTHEY RD <br /> LATHROP, CA 95330 <br /> Care of A&W FARMS <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0003662 10181271 <br /> Facility Name A&W FARMS <br /> Location 12965 S MANTHEY RD <br /> LATHROP, CA 95330 <br /> Phone 209-982-1517 x <br /> Mailing Address 12965 S MANTHEY RD <br /> LATHROP, CA 95330 <br /> care of A&W FARMS <br /> Location Code 99-UNINCORPORATED A Alt Phone <br /> BOS District 003 -BESTOLARIDES, STEVE Fax <br /> APN 19122005 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003240 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name A&W FARMS (Circle One) <br /> Account Balance as of 4/25/2016: $266.00 <br /> (Circle One) <br /> Program/Element and DescriptionRecord ID Employee ID and Name Status Transfer to Activa/Inacbe <br /> New Owner? Delete <br /> 1958-HM-Farm Operations PRO625925 EE0002670-MUNIAPPA NAIDU Active Y N A I D <br /> 2220-SM HW GEN<5 TONSNR PRO530650 EE0001459-VICKI MCCARTNEY Active Y N A D <br /> 2332-EXEMPT TANK FACILITY PR0234092 EE0001459-VICKI MCCARTNEY Active,l Y N A D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PRO507383 EE0000451 -STEVE SASSON Inactive Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PRO530649 EE0001469-VICKI MCCARTNEY Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0533991 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specrriq 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 and/or Standards and State and/or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: V VZ4'f <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: • V\ AA4-ffY1-1 Date Account out: (i1 Date l ZSI� <br /> COMMENTS. <br /> ' JOY. T'. , Invoice#: <br />