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Date run 3/14/2014 8:46:41AI1 SAN NW JIN COUNTY ENVIRONMENTAL HEA-mW/ DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 3/14/2014 Pagel <br /> Record Selection Criteria: Facility ID FA0016973 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0013814 New Owner IB <br /> Owner Name EDDIE &JUDY PIAZZA <br /> Owner DBA EDDIE &JUDY PIAZZA <br /> Owner Address 1155 GILLIS RD <br /> STOCKTON, CA 95215 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 1155 GILLIS RD <br /> STOCKTON, CA 95215 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0016973 10185703 <br /> Facility Name EDDIE &JUDY PIAZZA <br /> Location 1155 GILLIS RD <br /> STOCKTON, CA 95215 <br /> Phone 209466-7118 x0 <br /> Mailing Address 1155 GILLIS RD <br /> STOCKTON, CA 95215 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 17329017 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 AR0029855 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility ! Account <br /> Account Name EDDIE L&rd:G�D-�A (c;rcle one) <br /> Account Balance as of 311412014: <br /> (Circle One) <br /> Transfer to Active/Ina0ve <br /> Progran-dElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PR0525158 Active Y N AD <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0530609 EE0000753-WILLY NG Active,[ Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532132 Inactive 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,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identifed 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 and/or <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date I I <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date 1 ! <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> PaymentTye Check Number Receiv d by <br /> RENS: l � DateI1 Account out: Date 3 111 <br /> COMMENTS: <br /> (,Q sL P['ll-lk-j Oee� A-jti do 31 (311`l XrV&-X M4(-"t I'10 <br /> -373 - 3 6f ��, ` OkA. W o-s C.�'ir11� zr N lj'e- GV I � 0 � f ttx, yow(\' <br /> �-'�f�'�/ "� t't' Y"4b �d�j M� 1 IF] PJ�t#'l. Tit 1!- tet- � L , <br />