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Date run 10/26/2018 4:00:48P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by ti Pagel <br />Facility Information as of 10/26/2018 <br />Record Selection Criteria: Facility ID FA0017151 <br />OWNER FILE INFORMATION Number of facilities for this owner : 1 <br />Owner ID <br />OW0013992 <br />Owner Name <br />HWY 12 FARMS INC <br />Owner DBA <br />HWY 12 FARMS INC <br />OwnerAddress <br />11961 W HWY 12 <br />Active <br />LODI, CA 95242 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-472-1313 <br />Mailing Address <br />3840 BROOK VALLEY CIR <br />N <br />STOCKTON, CA 95219 <br />Care of <br />PR0530511 <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0017151 10185975 <br />Facility Name HWY 12 FARMS INC <br />Location 11961 W HWY 12 <br />LODI, CA 95242 <br />Phone 209-483-5885 x0 <br />Mailing Address 3840 BROOK VALLEY CIR <br />STOCKTON, CA 95219 <br />Care of MLQhaef-Ssr+yeft <br />Location Code <br />BOS District <br />APN 02507001 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Make changestcorrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />go GA- <br />; Ire✓ G. <br />501 <br />Alt Phone <br />Fax <br />EMail : <br />Account ID AR0030033 <br />Mail Invoices to Account Mail Invoices to <br />Account Name HWY 12 FARMS INC <br />Account Balance as of 10/26/2018: $190.00 <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description <br />Record ID <br />Employee ID and Name <br />Status <br />New Owner? elet <br />1958 - HM -Farm Operations <br />PRO525336 <br />EE0002670 - MUNIAPPA NAIDU <br />Active <br />Y <br />N <br />. 2221 - USED OIL ONLY - <5 TONS/YR <br />PR0539061 <br />EE0000030 -AARON HANG <br />Active <br />Y <br />N <br />qy <br />2830 - AST FAC - SPCC EXEMPT <br />PR0530511 <br />EE0000030 -AARON HANG <br />Active <br />Y <br />N <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGI <br />PRO534144 <br />InactivE <br />Y <br />N A <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 and/or Standards and State ancitor <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />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 />E H D Staff: vYIM�d1'br' Date /4 / d( l f� Account out: Date <br />COMMENTS: 1 <br />SrtP- Vis+/ l0 1l 7//P lY1e ac, if Invoice#: <br />