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Date run 10/8/2018 11:56:55AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 45021 <br />Run by Pagel <br />' Facility Information as of 10/8/2018 <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 />Owner Address <br />11961 W HWY 12 <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 />STOCKTON, CA 95219 <br />1� <br />1\►v <br />Care of <br />FACILITY FILE INFORMATION <br />I <br />Facility ID/CERS ID <br />FA0017151 10185975 <br />Facility Name <br />HWY 12 FARMS INC <br />Location <br />11961 W HWY 12 <br />LODI, CA 95242 <br />Phone <br />209-483-5885 x0 <br />Mailing Address <br />3840 BROOK VALLEY CIR <br />TOCKTON, CA 95219 <br />Care of <br />Michael Scriven <br />Location C die <br />BOS District <br />APN <br />02507001 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0030033 <br />Mail Invoices to Account <br />Account Name HWY 12 FARMS INC <br />Account Balance as of 10/8/2018: $190.00 <br />Program/Element and Description <br />X11 <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 />/ Phone <br />Fax <br />EMail: <br />New Account ID: <br />Mail Inv, es to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Record ID Employee ID and Name Status New Owner? Delete <br />1958 - HM -Farm Operations I' PR0525336 EE0002670 - MUNIAPPA NAIDU Active Y N A I D <br />2221 - USED OIL ONLY - <5 TONS/YR PR0539061 EE0000030 - AARON HANG Active Y N A I D <br />2830 - AST FAC - SPCC EXEMPT PR0530511 EE0000030 - AARON HANG Active Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0534144 Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, 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 and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />EHD Staff. <br />COMMENTS: <br />Date <br />' $25.00 = Amount Paid Date <br />Amount Paid Date <br />Date <br />Received by <br />Account out: Date / <br />/? D f <br />In oice #: <br />S ��_y��3 SBS <br />