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Date run 4/25/2016 10:44:02AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 4/25/2016 Record Selection Criteria: Facility ID FA0003662 BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andror project specific, PHS/EHD hourly charges associated with this facility 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 andror Federal Laws. APPLICANT'S SIGNATURE: ✓' I "`�" G� Cy41 Ua/t\e / / Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Received by V1 _ EHD Staff: • A �+4-(/N Date �_/_/_LL_ Account out: Date _ / Z`� /f COMMENTS: ' ah; �J � Invoice #: d .r / M� - Mu.K.i — 070�- ''`°� �'` 0� sem . Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) OWNER FILE INFORMATION Number of facilities for this owner : 2 SSN / Fed Tax ID Owner ID OW0002732 New Owner ID Owner Name A & W FARMS Owner DBA A & W FARMS OwnerAddress 12965 S MANTHEY RD LATHROP, CA 95330 Home Phone Not Specified Work/Business Phone 209-993-6869 Mailing Address 12965 S MANTHEY RD LATHROP, CA 95330 Care of A & W FARMS FACILITY FILE INFORMATION Facility ID / CERS ID FA0003662 10181271 Facility Name A & W FARMS Location 12965 S MANTHEY RD LATHROP, CA 95330 Phone 209-982-1517 x ' Mailing Address 12965 S MANTHEY RD LATHROP, CA 95330 Care of A & W FARMS Location Code 99 - UNINCORPORATED A Alt Phone BOS District 003 - BESTOLARIDES, STEVE Fax APN 19122005 EMail: EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0003240 New Account ID: Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account Account Name A & W FARMS (Circle One) Account Balance as of 4/25/2016: $266.00 (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1958 - HM -Farm Operations PR0525925 EE0002670 - MUNIAPPA NAIDU Active Y N A I D 2220 - SM HW GEN <5 TONS/YR PR0530650 EE0001459 - VICKI MCCARTNEY Active Y N A D 2332 - EXEMPT TANK FACILITY PR0234092 EE0001459 - VICKI MCCARTNEY Active,l Y N A D 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0507383 EE0000451 - STEVE SASSON Inactive Y N A I D 2830 -AST FAC - SPCC EXEMPT PR0530649 EE0001459 - VICKI MCCARTNEY Inactive Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARGI PR0533991 Inactive Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andror project specific, PHS/EHD hourly charges associated with this facility 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 andror Federal Laws. APPLICANT'S SIGNATURE: ✓' I "`�" G� Cy41 Ua/t\e / / Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Received by V1 _ EHD Staff: • A �+4-(/N Date �_/_/_LL_ Account out: Date _ / Z`� /f COMMENTS: ' ah; �J � Invoice #: d .r / M� - Mu.K.i — 070�- ''`°� �'` 0� sem .