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Date run 3/23/2016 9:59:45AR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 715021 <br /> Run by Pagel <br /> Facility Information as of 3/23/2016 <br /> Record Selection Criteria: Facility ID FA0003168 <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 OW0002364 New Owner ID <br /> Owner Name HALEY, JIM <br /> Owner DBA HALEY FARMS <br /> Owner Address 1033 LADD RD <br /> MODESTO, CA 65356 <br /> Home Phone 209-545-2731 <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 576218 <br /> MODESTO, CA 95357 <br /> care of HERNANDEZ, KIM <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0003168 <br /> Facility Name HALEY FARMS <br /> Location 5793 DELTA AVE <br /> TRACY, CA 95376 <br /> Phone <br /> Mailing Address PO BOX 576218 <br /> MODESTO, CA 95357 <br /> Care of HERNANDEZ, KIM <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 005 - ELLIOTT, BOB Fax <br /> APN 21310005 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name HALEY FARMS <br /> Title <br /> Day Phone 209-545-2731 <br /> Night Phone 209-545-2731 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002733 New Account ID: <br /> Mail lnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name HALEY FARMS (Circle One) <br /> Account Balance as of 3/23/2016: $0.00 <br /> (Circle One) <br /> Transfer to Activeanactve <br /> ProgranvElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4443-SW COMPOST SITE PR0519205 EE0009000-HARPRIT MATTU Active Y N A I D <br /> 4452-POULTRY RANCH>100,000 BIRDS PR0400043 EE0003973-ROBERT MCCLELLON Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on thisform Ialso certifythat all operations will he performed in accordance with all applicable Ordinance Codes andor Standards and State andor <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: Date / / Account out: Date <br /> COMMENTS: Invoice#: <br />