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9:13:43AIt SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#502Facility Information as of 212412015 Pagel <br /> [Date <br /> teria: Facility 0 FA0016700 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE (date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 OWNERSHIP CHANGE(date) <br /> SSN/Fed Tax ID <br /> Owner ID OW0013541 New Owner ID <br /> Owner Name VEZALDENOS FARM <br /> Owner DBA VEZALDENOS FARM <br /> Owner Address 818 E FRENCH CAMP RD <br /> FRENCH CAMP, CA 95231 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 818 E FRENCH CAMP RD <br /> FRENCH CAMP, CA 95231 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0016700 10185261 <br /> Facility Name VEZALDENOS FARM <br /> Location 818 E FRENCH CAMP RD <br /> FRENCH CAMP, CA 95231 <br /> Phone 209-982-1499 x0 <br /> Mailing Address 818 E FRENCH CAMP RD h Lid <br /> FRENCH CAMP, CA 95231 <br /> Care of <br /> Location Code 99 - UNINCORPORATED p Alt Phone <br /> BOS District 001 -VILLAPUDUA, CA'RLOS Fax <br /> APN 17749008 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 o,R0029582 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility ! Account <br /> Account Name VEZALDENOS FARM (circle one) <br /> Account Balance as of 212412015: $79.00 ttvL- j <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Programimement and Description Record ID Employee ID and Name Status New Owner? D to <br /> 1958.HM-Farm Operations PR0524885 EE0008709-JAMIE DE LA ROSA Active Y N A D <br /> 2220-SM HW GEN<5 TONSIYR PR0530199 EE0002646-THUY TRAN Inactive Y N A D <br /> 2830-AST FAC -SPCC EXEMPT PRO530198 EE0002646-THUY TRAActive Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532000 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of sameacknowledge that all site,and/or project specific,P"SrEH'D 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 andlor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE:. Date 2 /�I <br /> Program Records to be TRANSFERED: "$25.00 e Amount Paid Date I / <br /> Waiter System to be TRANSFERED Amount Paid Date ! ! <br /> Payment Type Check Number Received b f <br /> RENS: Date / 1 jam, Account out Date 13�? ! <br /> COMMENTS' <br />