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ESelection <br /> /2015 12:04:52PI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Report#5021 <br /> Facility Information as of 3/20/2015 Paget <br /> teria: Facility ID FA0017545 <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: 1 <br /> SSN/Fed Tax ID <br /> Owner ID OW0014386 New Owner ID <br /> Owner Name LAGORIO BROS FARMS <br /> Owner DBA LAGORIO BROS FARMS <br /> Owner Address 20001 E FLOOD RD <br /> LINDEN, CA 95236 <br /> Home Phone Not Specified <br /> Work/Business Phone 209_887-2141 <br /> Mailing Address 20001 E FLOOD RD <br /> LINDEN, CA 95236 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0017545 10186625 <br /> Facility Name LAGORIO EROS FARMS <br /> Location 19108 E TOBACCO RD <br /> LINDEN, C <br /> Phone - 7-2141 x0 <br /> Mailing Ad ss 18600 Tobacco Road (� <br /> LINDEN, CA 95236 <br /> Care of Brett Lagorio m p <br /> Lo ation Code Alt Phone <br /> B S Distri Fax :F6 i <br /> APN 10514003 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID gR0030427 New Account <br /> Mail Invoices to Account Mail Invoices to: Owner I acilit 1 Account <br /> Account Name LAGORIO BROS FARMS (Circ nej <br /> Account Balance as of 3/20/2015-. $0.00 <br /> (Circle One) <br /> Transfer to Activellnael <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PRO525730 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2220-SM HW GEN<5 Ti PRO530611 EE0009488-JEFFREY WONG Active Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PR0530610 EE0009488-JEFFREY WONG Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533141 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,andlor 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 andar Standards and State and'or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I ! <br /> Program Records to be TRANSFERED. *$25.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date I <br /> Payment Type Check Number Received by <br /> RENS: Date Account out: LA Date I_ I� <br /> COMMENTS: 1 / / <br /> 4 C? <br /> 4- <br />