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Date run 10/6/2017 4:16:08PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/6/2017 <br /> Record Selection Criteria: Facility ID FA0017170 <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 SSN/Fed Tax ID <br /> Owner ID OW0014011 New Owner ID <br /> Owner Name MORAIS FARMS <br /> Owner DBA MORAIS FARMS <br /> Owner Address 1836 RAMONA AVE <br /> STOCKTON, CA 95204 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 1836 RAMONA AVE <br /> STOCKTON, CA 95204 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0017170 10186009 <br /> Facility Name MORAIS FARMS <br /> Location 11551 GUARD RD <br /> LODI, CA 95240 <br /> Phone 209-471-5479 x0 <br /> Mailing Address 1836 RAMONA AVE <br /> STOCKTON, CA 95204 X3 kW <br /> Care of <br /> Location Code Alt Phone <br /> BOS District FaxITO <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 / Account <br /> Account Name MORAIS FA U nr�_ (Circle One) <br /> Account Balance as of 10/6/2017: 00 <br /> (Circle One) <br /> Transfer to AcliveRnactve <br /> PrograMElement and Desedption Record ID Employee ID and Name Status New Owner? �'D-ele�te <br /> 1958-HM-Farm Operations PRO525355 EE0002670-MUNIAPPA NAIDU Active Y N A.L i iv <br /> 2830-AST FAC -SPCC EXEMPT PRO530507 EE0000030-AARON HANG Inactive Y N A 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 that all site,evictor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form I also cartify that all operations will be performed in accordance with all applicable Ordinance Codes anti Standards and State ancvor <br /> Federal Laws, <br /> APPLICANT'S SIGNATU Date 1 <br /> Program Records to be TRANSFERE '$25.00= Amount Paid Date / / <br /> Water System to be TRANSFEREDJ Amount Paid Date <br /> Payment Type Check Number Received by <br /> EHD Staff: Date / / Account out: Date Ai9f <br /> COMMENTS: <br /> Invoice#: <br /> u � <br />