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Dater'r. . .1688/2018 9:41:01A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report #5021 Run by Pagel Facility Information as of 10/18/2018 Record Selection Criteria: Facility ID FA0017066 OWNER FILE INFORMATION Number of facilities for this owner Owner ID OW0013907 Owner Name A&D RANCH Owner DBA A&D RANCH Owner Address 2966 BEYER LN Phone STOCKTON, CA 95215 Home Phone Not Specified Work/Business Phone 209-481-5833 Mailing Address 2966 BEYER LN Location Code STOCKTON, CA 95215 Care of FACILITY FILE INFORMATION Facility ID / CERS ID FA0017066 10185839 Facility Name A&D RANCH Location 1980 WHITE LN STOCKTON, CA 95215 Phone 209-992-5027 x Mailing Address 2966 BEYER LN STOCKTON, CA 95215 Care of Donald Giannecchini Location Code BOS District APN 10108024 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0029948 Mail Invoices to Account Account Name A&D RANCH Account Balance as of 10/18/2018: $101.00 Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) 1 SSN/Fed Tax ID New ner,ID Z_-0-0,57 ftW t' Alt Phone Fax EMail : Mail Invoices to New Account ID: : Owner / Facility / Account (Circle One) (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1958 - HM -Farm Operations PR0525251 EE0002670 - MUNIAPPA NAIDU Active Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0533912 Inactive Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this facility 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 Federal Laws. APPLICANT'S SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number EHD Staff: COMMENTS: Date * $25.00 = Amount Paid Date ! / Amount Paid Date Received by Date / / Account out: LI Date h / / 3 / a Invoice #: