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Date run 11/13/2018 1:40:40P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 11/13/2018 <br /> Record Selection Criteria: Facility ID FA0017259 <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 OW0014100 New Owner ID : <br /> Owner Name MOTOIKE FARM ` r <br /> Owner DBA MOTOIKE FARM y yo S Far M <br /> OwnerAddress 1700 N JACK TONE RD 'Poidt sta 1-n <br /> STOCKTON, CA 95215 C-A °152�1n <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 1700 N JACK TONE RD ?')OM Nyr)d-e_�-CI 1_0 <br /> STOCKTON, CA 95215 tAfyxh_ CA <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017259 10186163 <br /> Facility Name MOTOIKE FARM Pad �t U ��c`ne r 5 iCs�C m <br /> Location 1700 N JACK TONE RD 1�0U t�1 SDCTO�I� �d <br /> STOCKTON, CA 95215 TU 52l <br /> Phone 209-931-0259 x0 U2_6 W?)-i- <br /> Mailing Address 1700 N JACK TONE RD ?)OCbO N 'Po61s-t-a LY1 <br /> STOCKTON, CA 95215 Lknaluggs , Cp� eA523�e <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 10502007 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name V-1m\A'a` L\t <br /> Title <br /> Day Phone Z F'o7- <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0030141 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name MOTOIKE FARM (Circle One) <br /> Account Balance as of 11/13/2018: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> • 1958-HM-Farm Operations PR0525444 EE0002670-MUNIAPPA NAIDU Active YD <br /> 2840-AST EXEMPT FAC < 1,320 GAL PR0530296 EE0000753-WILLY NG Inactive Y NNwiththis <br /> D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0532232 Inactive Y ND <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: [,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project speck,PHS/EHD hourly charges associatecility <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 anclor Standards and State and/or <br /> Federal Laws, <br /> APPLICANT'S 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: C��X_d x.\ aDate k_/ 1-6 /1Z Account out: Date I <br /> COMMENTS: <br /> Ir1VOICe#: <br />