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Date run 10/26/2017 11:58:25/ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/26/2017 <br /> Record Selection Criteria: Facility ID FA0017170 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID : <br /> Owner ID OW0014011 New Owner ID : <br /> � <br /> Owner Name MO {.A}� A <br /> &- 6 i l i O /"1 yore is aro Rio-An /I( <br /> Owner DBA MORAIS FARMS <br /> Owner Address -7 a A Tr ae li rd Dr— <br /> Fr Y."Lpei _ 1 -)cn5lli;in �R7_SO <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017170 10186009 <br /> Facility Name MORAIS FARMS <br /> Location 11551 GUARD RD <br /> LODI, CA 95240 <br /> Phone 869.474-647$-4Q- <br /> Mailing Address 1 <br /> rr . N4r�✓ ti° 9 zSd <br /> Care of <br /> Location Code Alt Phone <br /> BOIS District Fax <br /> APN 05506003 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 AR0030052 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility if Account <br /> Account Name MORAIS FARMS (Circle One) <br /> Account Balance as of 10/26/2017: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Omen Delete <br /> 1958-HM-Farm Operations PR0525355 EE0002670-MUNIAPPA NAIDU Active Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PRO530507 EE0000030-AARON HANG Inactivr Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533362 InactivE Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge Nat all site,andor project specific,PHSrEHD 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 andor standards and State andor <br /> Federal Lame. <br /> APPLICANTS SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date ! I <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> EHD Staff: Date / /� Account out: Date ! 1�7 <br /> COMMENTS: <br /> Invoice#: <br />