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Date run 9/11/2015 1:12:09PK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 9/11/2015 <br />Record Selection Criteria: Facility ID FA0022531 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID OW0020070 <br />Owner Name Michael Phillips <br />Owner DBA <br />Owner Address <br />Home Phone Not Specified <br />Work/Business Phone 209-368-7384 <br />Mailing Address 4580 W. Hwy 12 <br />Lodi, CA 95242 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0022531 10509637 <br />Facility Name <br />Bare Ranch Shop <br />Location <br />19877 W WOODBRIDGE RD <br />Lodi, CA 95242 <br />Phone <br />209-368-7384 x <br />Mailing Address <br />4580 W. Hwy 12 <br />Lodi, CA 95242 <br />Care of <br />Phillips Farms LLC <br />Location Code <br />COMMENTS: �7 <br />BOS District <br />n <br />APN <br />Invoice #: <br />laud - <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0041211 <br />Mail Invoices to Account <br />Account Name Emiliano Castanon <br />Account Balance as of 9/11/2015: $0.00 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN /Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />Mail Invoices to <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />MaZimmon <br />Description Record ID Employee ID and Name Status New Owner? Delete <br />Materials PR0539422 EE0008709 - JAMIE DE LA ROSA Active Y N A I D <br />2220 - SM HW GEN <5 TONS/YR PR0539421 EE0001422 - ARIS VELOSO Active Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andlor 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 and/or Standards and State andlor <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: <br />" $25.00 = <br />Amount Paid <br />Date ! / <br />Water System to be TRANSFERED: <br />Amount Paid <br />Date <br />Payment Typee <br />Check Number <br />Received by <br />EHD Staff: L�/t' o' fly. <br />Date C_/ I Account out:IL: Date <br />COMMENTS: �7 <br />�Yin <br />n <br />nc <br />Invoice #: <br />laud - <br />