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Date run 2/11/2015 2:48:28K SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 45021 <br />Run by Pagel <br />Facility Information as of 2/11/2015 <br />Record Selection Criteria: Facility ID FA0000818 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0000644 <br />Owner Name <br />J M DAIRY <br />Owner DBA <br />J M DAIRY <br />Owner Address <br />11500 E FRENCH CAMP RD <br />4467 - AG/CANNERY WASTE FEED YARD <br />MANTECA, CA 95336 <br />Home Phone <br />209-982-1722 <br />Work/Business Phone <br />209-982-1722 <br />Mailing Address <br />11500 E FRENCH CAMP RD <br />hourly charges associated with this facility <br />MANTECA, CA 95336 <br />Care of <br />J M DAIRY <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0000818 10180659 <br />Facility Name J M DAIRY <br />Location 11500 E FRENCH CAMP RD <br />MANTECA, CA 95336 <br />Phone 209-982-1722 x <br />Mailing Address 11500 E FRENCH CAMP RD <br />MANTECA, CA 95336 <br />Care of J M DAIRY <br />Location Code 99 - UNINCORPORATED P <br />Bos District 005 - ELLIOTT, BOB <br />APN 20608007 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0000816 <br />Mail Invoices to Facility O( �- <br />Account Name J M DAIY"� <br />Account Balance as of 2/11/2015:E002.pp, 0511 <br />ProgranVElement and Description <br />Record ID <br />Make changes/corrections in RED ink. I <br />INFORMATION CHANGE (date) % <br />is - <br />OWNERSHIP CHANGE (date) <br />SSN/Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />or � Mail Invoices to: <br />/tenn.// ., <br />Employee ID and NaMe <br />New Account ID; : _ <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inaclve <br />Status New Owner? Delete <br />1958 - HM -Farm Operations <br />PR0525775 <br />EE0002474 - MICHAEL PARISSI <br />Active Y N A I D <br />SM HW GEN <5 TONS/YR <br />283 AST FAC - SPCC EXEMPT <br />PRO538980 <br />PR0530200 <br />EE0009001 - ELENA MANZO <br />EE0009001 - ELENA MANZO <br />Active Y N A I D <br />Active Y N A (I D <br />4467 - AG/CANNERY WASTE FEED YARD <br />PR0440041 <br />EE0002620 - ALFONSO ARAMBULA <br />Active Y N A D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0533721 <br />Inactiv( Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHSrEHD <br />hourly charges associated with this facility <br />or activity billed to the party identifiedas the OWNER <br />,on.this form. I also certify that all operations <br />Federal Laws <br />will be performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or <br />'F�r►�'� lQss - .., < <br />/willll�ba <br />��.1 �(�L��IL� <br />pt 2830 <br />. (� <br /><3Zo s4a-y <br />APPLICANT'S SIGNATURE: <br />Date I <br />l �1yj <br />Program Records to be TRANSFERED: <br />" $25.00 = <br />Amount Paid Date <br />Water System to be TRANSFERED: <br />Amount Paid Date <br />Payment Type Check Number <br />Received b <br />REHS: 7IC .. (�� C/`�. <br />Date �`/ �/ <br />Account out:7 Date <br />%' / `/�//A <br />COMMENTS: <br />"' <br />O� <br />