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Date run 3/14/2017 9:09:24AN SAN JO, IN COUNTY ENVIRONMENTAL HEAL )EPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/14/2017 <br /> Record Selection Criteria: Facility ID FA0007393 <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: 2 SSN/Fed Tax ID <br /> Owner ID OW0006105 Case Number: 002447 New Owner ID <br /> Owner Name TOSTA, HENRY DAIRY LLP <br /> Owner DBA TOSTA, HENRY DAIRY <br /> Owner Address 20662 SAN JOSE RD <br /> TRACY, CA 95304 <br /> Home Phone 209-836-1286 <br /> Work/Business Phone 209-835-0687 <br /> Mailing Address 20662 SAN JOSE RD <br /> TRACY, CA 95304 <br /> Care of HENRY TOSTA <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0007393 <br /> Facility Name TOSTA#1 HENRY 39-421 <br /> Location 20662 SAN JOSE RD <br /> TRACY, CA 95304 <br /> Phone 209-836-1286 <br /> Mailing Address 20662 SAN JOSE RD <br /> TRACY, CA 95304 <br /> Care of HENRY TOSTA <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 005 - ELLIOTT, BOB Fax <br /> APN 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 AR0011126 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name TOSTA#1 HENRY 39-421 (Circle One) <br /> Account Balance as of 3/14/2017: $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 /> 2011 -GRADE A DAIRY PR0506396 EE0005362-NICHOLAS WIESEMAN Inactive Y N A I D <br /> 2775-EMPLOYEE HOUSING-DAIRY EXEMPTION PR0522676 EE0000321 -GREG OLIVEIRA Active Y N A �) D <br /> 4620-DAIRY- WATER SUPPLY WA0515622 EE0005362-NICHOLAS WIESEMAN Active Y N A TT 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. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or 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 y <br /> EHD Staff: -ALC Date Account out: Date <br /> COMMENTS: <br /> Invoice#: <br /> Com- <br />