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Date run 10/15/2018 12:53:10F SAN JOAQUIN COUI"TY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/15/2018 <br /> Record Selection Criteria: Facility ID FA0017137 <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 OW0013978 New Owner ID <br /> Owner Name COSTA& COSTA FARMS INC <br /> Owner DBA COSTA& COSTA FARMS INC <br /> Owner Address 4484 W TREDWAY RD <br /> LODI, CA 95242 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-321-1217 <br /> Mailing Address 4484 W TREDWAY RD <br /> LODI, CA 95242 5 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017137 10185953 <br /> Facility Name COSTA& COSTA FARMS INC <br /> Location 11789 N THORNTON RD <br /> LODI, CA 95242 <br /> Phone 209-366-1440 x <br /> Mailing Address 4484 W TREDWAY RD 0 <br /> LODI, CA 95242 err q_J52_4) <br /> Care of Patrick Costa <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 05519005 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 AR0030019 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name COSTA& COSTA FARMS INC (Circle One) <br /> Account Balance as of 10/15/2018: $101.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PR0525322 EE0002670-MUNIAPPA NAIDU Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0529155 EE0000030-AARON HANG Inactive Y N A I D <br /> 2840-AST EXEMPT FAC < 1,320 GAL PR0529154 EE0000030-AARON HANG Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534315 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD 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 andror Standards and State andror <br /> Federal Laws. <br /> APPLICANT'S 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 / / Account out: Date�/ S/ <br /> COMMENTS: <br /> Invoice#: <br />