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Date run 6/10/2015 3:40:28K SAN JO 'JIN COUNTY'ENVIRONMENTAL HEAT DEPARTMENT Report#5021 O,un by � Pagel Facility Information as of 6/10/20 -lo Record Selection Criteria: Facility ID FA0016887 OWNER FILE INFORMATION Number of facilities for this owner Owner ID OW0013728 Owner Name ABA FARMS Owner DBA ABA FARMS Owner Address 16505 S TRACY BLVD 209-835-0406 x0 TRACY, CA 953D Home Phone Not Specified Work/Business Phone 209-835-0406 Mailing Address 16505 S TRACY BLVD 99 - UNINCORPORATED P TRACY, CA 95304 Care of APN FACILITY FILE INFORMATION Facility ID/ CERS ID FA0016887 10185571 Facility Name ABA FARMS Location 9447 HOWARD RD Delete STOCKTON, CA 95206 Phone 209-835-0406 x0 Mailing Address 16505 S TRACY BLVD A TRACY, CA 95304 Care of Steve Arnaudo Location Code 99 - UNINCORPORATED P Bos District 003 - BESTOLARIDES, STEVE APN 18915006 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Active Title A Day Phone ERSC - ELECTRONIC REPORTING STATE SURCHARG Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN/Fed Tax ID New Owner ID : Alt Phone Fax EMail : Account ID AR0029769 Mail Invoices to Account Mail Invoices to: Account Name ABA FARMS Account Balance as of 6/10/2015: $213.00 New Account ID: : Owner / Facility / Account (Circle One) (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1958 - HM -Farm Operations PR0525072 EE0009817 - ROBERT LOPEZ Inactive Y N A I D 2220 - SM HW GEN <5 TONS/YR PR0539996 EE0005642 - MICHELLE HENRY Active Y N A I D 2830 - AST FAC - SPCC EXEMPT PR0530352 EE0002646 - THUY TRAN Active Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0531856 Inactive 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 Ordinance 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 EHD Staff: COMMENTS: $25.00 = Date Date / / Amount Paid Date -/-/ _ Amount Paid Date Received by r Account out: &6 Date Invoice #: