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Date run 2/26/2016 4:52:26PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 2/26/2016 Pagel <br /> Record Selection Criteria: Facility ID FA0023327 <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 OW0021549 New Owner ID <br /> Owner Name E &J GALLO WINERY <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-613-8927 <br /> Mailing Address PO BOX 1130 <br /> MODESTO, CA 95353 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0023327 10631008 <br /> Facility Name Gallo Vineyards, Inc. <br /> Location 28750 N Sowles Rd <br /> Galt, CA 95632 <br /> Phone 209-744-1142 x <br /> Mailing Address 28750 N SOWELS ROAD <br /> GALT, CA 95632 <br /> Care of GALLO VINEYARDS, INC. <br /> Location CodeI,� Alt Phone <br /> BOS District 7 ,/ Fax <br /> APN 00-7/(D 0'f' 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 AR0042948 New Account ID: <br /> Maillnvoicesto Account Mail Invoices to: Owner / Facility / Account <br /> Account Name PARM DHALIWAL (Circle One) <br /> Account Balance as of 2/26/2016: $0.00 <br /> (Circle One) <br /> Transfer to Activelmiave <br /> Program/Element and Description Record ID Employee ID and Name Status New Owml Delete <br /> 1920-HMBP-Common Materials PRO540805 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anclor project specific,PHSEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. Ialso certify that all operations will be performed in accordance with all applicable Ordinance Codes andfor Standards and State anclor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: •$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: , Amount Paid Date <br /> Payment Type Check Number Received by <br /> EHD Staff: Date Accountout: Date <br /> COMMENTS: o <br /> Invoice#: L 778' 9 r-- <br /> CAk-P(1kq <br /> VAR CSS <br />