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Date run 3/13/2012 4:30:11PI1 SAN JC UIN COUNTY ENVIRONMENTAL HEA" 1 DEPARTMENT Report#5021 Runbv Pagel w Facility Information as of 3/13/2011 Record Selection Criteria: Facility ID FA0017395 OWNER FILE INFORMATION Owner ID OW0014236 Owner Name DASILVA DAIRY Owner DBA DASILVA DAIRY Owner Address 16880 S HENRY RD Phone ESCALON, CA 95320 Home Phone Not Specified Work/Business Phone Not Specified Mailing Address ,16$8Q S-HEMRY RD PR0525580 ESCALON, CA 95320 Care of A I D FACILITY FILE INFORMATION Facility ID FA0017395 Facility Name DASILVA DAIRY Location 16551 S HENRY RD ESCALON, CA 95320 Phone 209-838-1121 Mailing Address 16880S-J}Efqft"0 Status ESCALON, CA 95320 Care of Location Code 99 - UNINCORPORATED)b BOS District 004 - VOGEL, KEN APN EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0030277 Mail Invoices to Owner Account Name DASILVA DAIRY Account Balance as of 3/13/2012: $815.00 Make changes/corrections in RED ink. 1 1 7 INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID I -7-1 LA . Alt Phone Fax EMail : New Account ID: : Mail Invoices to: Owner / Facility / Account (Circle One) APPLICANT'S SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number REHS: COMMENTS \\eh-env\envision\reports\5021. rpt Date ' $25.00 = Amount Paid Date / ! Amount Paid Date Received by -7 Date / / Account out: W Date --77, GI,,N2wr^" L m� (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1958 - HM -Farm Operations PR0525580 Active Y N A I D 2220 - SM HW GEN <5 TONS/YR PR0529954 EE0002670 - MUNIAPPA NAIDU Active Y N A I D 2830 - AST FAC - SPCC EXEMPT PR0529953 EE0002670 - MUNIAPPA NAIDU Active,Exempt Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHPRO532762 Active Y N A I D 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 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 Ordinace Codes and/or Standards and State and/or Federal Laws APPLICANT'S SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number REHS: COMMENTS \\eh-env\envision\reports\5021. rpt Date ' $25.00 = Amount Paid Date / ! Amount Paid Date Received by -7 Date / / Account out: W Date --77, GI,,N2wr^" L m�