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Date run 7/16/2012 3:10:10Prt SAN JC UIN COUNTY ENVIRONMENTAL HEA . DEPARTMENT <br /> Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/16/2012 <br /> Record Selection Criteria: Facility ID FA0020880 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> j OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION _ SSN/Fed Tax ID <br /> Owner ID OW0015033 New Owner ID <br /> Owner Name PACIFIC COAST FARMERS MKT ASSN <br /> Owner DBA CERTIFIED FARMERS MARKET <br /> Owner Address 5060 COMMERCIAL CIR STE A <br /> CONCORD, CA 94520 <br /> Home Phone 925-825-9090 <br /> Work/Business Phone Not Specified <br /> Mailing Address 5060 COMMERCIAL CIR STE#A <br /> CONCORD, CA 94520 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0020880 <br /> Facility Name BROOKSIDE COUNTRY CLUB FARMERS MI <br /> Location 3603 ST ANDREWS DR <br /> STOCKTON, CA 952191868 <br /> Phone 925-825-9090 <br /> Mailing Address 5060 COMMERCIAL CIR STE#A <br /> CONCORD, CA 94520 <br /> Care of GLORIA BAKER, REGIONAL MGR <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 003- BESTOLARIDES Fax <br /> APN 11813005 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name GLORIA BAKER, REGIONAL MGR <br /> Title <br /> Day Phone 925-825-9090 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0037512 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name BROOKSIDE COUNTRY CLUB FARMERS MKT (Circle One) <br /> Account Balance as of 7/16/2012: $-125.00 <br /> (Circle One) <br /> Transfer to ActiveAnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1682-CERTIFIED FARMERS MARKET SITE PR0536347 EE0003361 -MARIBEL FLOHRSCHUTActive Y N A I D <br /> 1694-TEMPORARY EVENT VENDOR PR0536354 EE0003361 -MARIBEL FLOHRSCHUTActive Y N A I D <br /> 1694-TEMPORARY EVENT VENDOR PR0536414 EE0003361 -MARIBEL FLOHRSCHUTActive Y N A I D <br /> 1694-TEMPORARY EVENT VENDOR PR0537085 EE0003361 -MARIBEL FLOHRSCHUTActive Y N A I D <br /> 1694-TEMPORARY EVENT VENDOR PR0537086 EE0003361 -MARIBEL FLOHRSCHUTActive Y N A I D <br /> 1694-TEMPORARY EVENT VENDOR PR0537087 EE0003361 -MARIBEL FLOHRSCHUTActive Y N A I D <br /> 1695-TEMPORARY EVENT PR0536348 EE0003361 -MARIBEL FLOHRSCHUTActive Y N A I D <br /> 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 <br /> or activity will be billed to the party identified as the OWNER on this form 1 also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State andlor <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 Typ Check Number Received by <br /> REHS: // Date /�(Q/ Account out: D^�ate <br /> COMMENTS: f eV /�, 5 O PC M a O1/�v C✓ (}rte <br />