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Date run : 12/27/00 12:36:28PM SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Report #: 0002 <br /> Run by MLAGORIO Facility Information as of 12/27/00 Page #: 1 <br /> Record Selection Criteria: FacilityID FA0012689 <br /> Record ID <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE (date) <br /> OWNERSHIP CHANGE (date) <br /> OWNER FILE INFORMATION <br /> Owner ID: OW0009879 New Owner ID <br /> Owner Name; PELLEGRI FARMS <br /> Owner DBA• <br /> Owner Address; 21606 EL RANCHO RD <br /> TRACY, CA 95376- <br /> Home Phone: 209-482-2520 <br /> Work/Bussness Phone: Not Specified <br /> Mailing Address; 21606 EL RANCHO RD <br /> TRACY, CA 95376- <br /> Care of; RICHARD PELLEGRI <br /> FACILITY FILE INFORMATION <br /> Facility ID: FA0012689 <br /> Facility Name: PELLEGRI FARMS <br /> Location; 21606 EL RANCHO RD <br /> TRACY, CA 95376 <br /> Phone: 209-482-2520 n <br /> Mailing Address: 21606 EL RANCHO RD <br /> TRACY, CA 95376- <br /> Care of; RICHARD PELLEGRI �/' <br /> Location Code: nVf1 _ / //VV,�(� N; ,�`�l L• <br /> SOS District 5 V/SL'_^ Y �61b Code; <br /> ACCOUNTS RECEIVABLE FILE INFORMATION `H^� ,,11� <br /> Account ID; AR0021102 New Account ID:: ,La" p/yy✓\ <br /> Mail Invoices to: Account Mail Invoices to; Owner/Facility/Accourt{IlJ1 <br /> Account Name; BROWN &CALDW ELL (Circle Onea <br /> Account Balance as of 12/27/00: $43.50 "A--✓I V L <br /> (Circle One) <br /> UST(s) Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status Linked New Owner? Delete <br /> 2950-ENVIRON ASSESS PRO516583 EE0000942-LAGORIO Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agentof same,acknowledge thatall site,and/or <br /> project specific,PHS/EHD hourly charges associated with this facility or activity wgl be billed to the party identified as the BILLING PARTY on this <br /> form. I also certify thatall operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and State and/or Federal <br /> Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$0.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$150.00= Amount Paid Date <br /> Payment Type Ch k Number Receipt Number Received by <br /> REHS: I Date / / Account out: Date_�l�ll3b <br /> 1.0.0.89.00 • <br />