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Date run x'/22/2008 11:22:59/ SAN JOAQ"'N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run 5y Page 1 <br /> Facility Information as of 10/22/200 <br /> Record Selection Criteria: Facility ID FA0015259 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0012238 New Owner ID : <br /> Owner Name OAST T A C-K 1 10 A Pro,pel-h e--5 :Ph L- <br /> Owner DBA <br /> Owner Address Pn <br /> � I gd <br /> PAI METTO FI x4220 /V y (p Z <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0015259 <br /> Facility Name WEST COAST TOMATO <br /> Location 2900 E HARDING WAY <br /> STOCKTON, CA 95205 <br /> Phone <br /> Mailing Address 2900 E HARDING WAY <br /> STOCKTON, CA 95205 <br /> Care of <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 - GUTIERREZ, STEVE Fax <br /> APN 14310020 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0026265 def New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Accoun <br /> Account Name (Circle One) <br /> Account Balance as of 10/22/2008: $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 /> 2950-ENVIRON ASSESS PR0522425 EEQO 644A Active Y N A I D <br /> r-� <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledg hat all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> 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 Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid 3 Date <br /> Water System to be TRANSFERED: "$372.00= Amount Paid Date <br /> Payment Type/nn Check Number � � Z S� Received by <br /> RENS: i v 1 Date ) 0 Account out: Date <br /> COMMENTS: PAYMENT <br /> (,twT, 18 b�r7 RECEIVED <br /> UCT 2 2 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL\\ hs-ehs I-nt\aPPs\envisions\re orfs\5021.r t HEALTH <br /> DEPARTMEN- <br />