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Date run 4/9/2015 4:22:07PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 4/9/2015 <br /> Record Selection Criteria: Facility ID FA0022853 <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 OW0020812 New Owner ID <br /> Owner Name West coast grape farming <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-272-3000 <br /> Mailing Address 6342 Bystrum road <br /> Ceres, CA 95307 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022853 10614328 <br /> Facility Name Shady Oaks Ranch <br /> Location 15800 N Thorton Rd <br /> lodi, CA 95242 <br /> Phone 209-272-3000 x <br /> Mailing Address 6342 bystrum road <br /> Ceres, CA 95307 <br /> Care of West Coast grape farming, inc <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 02520012 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0041923 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Frank Canela (Circle One) <br /> Account Balance as of 4/9/2015: $0.00 <br /> (Circle One) <br /> Transfer to Active/Iral <br /> PrograMEament and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PR0539978 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,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. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andfor Standards and State andor <br /> Federal Lewis <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 /> REHS: Date�/ g / Account out: Date / Z'-5 <br /> COMMENTS. <br /> CR + c>`9wAc t�L Pn o�,�c a r� vtA <br /> (Jt w 1 G kt <br /> 2//s ��3 <br />