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Date run 8/13/2013 10:01:08AI SAN JOA N COUNTY ENVIRONMENTAL HEAL'- JEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 8/13/2013 <br /> Record Selection Criteria: Facility ID FA0003359 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0002483 Case Number: 002445 New Owner ID <br /> Owner Name VAN VLIET BROS <br /> Owner DBA VAN VLIET BROS <br /> Owner Address 23234 E LONE TREE RD <br /> ESCALON, CA 95320 <br /> Home Phone_2Q9_6&7-_5e43 Zc,`t' 6C7_8:5g3 <br /> Work/Business Phone Not Specified <br /> Mailing Address 23234 LONE TREE <br /> ESCALON, CA 95320 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0003359 <br /> Facility Name CREEKSIDE DAIRY 39-355 <br /> Location 23234 E LONE TREE RD <br /> ESCALON, CA 95320 <br /> Phone 209-838-1180 <br /> Mailing Address 23234 E LONE TREE RD <br /> ESCALON, CA 95320 <br /> Care of LEO AND MIKE VAN VLIET <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 22905006 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name LEO AND MIKE VAN VLIET <br /> Title 7 sr6, <br /> Day Phone 209-838-418E <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002936 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name CREEKSIDE DAIRY 39-355 (Circle One) <br /> Account Balance as of 8/13/2013: $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 PR0200143 EE0005362-NICHOLAS WIESEMAN Active Y N A I D <br /> 2775-EMPLOYEE HOUSING-DAIRY EXEMPTION PR0515758 EE0002089-OMRAN SOOD Active Y N A I D <br /> 4620-DAIRY- WATER SUPPLY WA0515629 EE0004589-KADEANNE LINHARES Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ancl/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 andfor <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 /> REHS: Date / / Account out: Date 1 / <br /> COMMENTS: <br />