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Date run 2/19/2015 4:12:13PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/19/2015 <br /> Record Selection Criteria: Facility ID FA0003341 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) 2 I <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN/Fed Tax ID <br /> Owner ID OW0013669 Case Number: 002452 New Owner ID <br /> Owner Name KISST, JOHN G &TAMELA <br /> Owner DBA KISST DAIRY <br /> Owner Address 20000 CEDAR AVE <br /> TRACY, CA 95304 <br /> Home Phone 209-832-3077 <br /> Work/Business Phone 209-538-8708 <br /> Mailing Address PO BOX 300 <br /> RIPON, CA 95366 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0003341 10181095 <br /> Facility Name KISST DAIRY <br /> Location 20000 CEDAR AVE <br /> TRACY, CA 95304 <br /> Phone 209-832-3077 x0 <br /> Mailing Address PO BOX 300 <br /> RIPON, CA 95366 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 005 - ELLIOTT, BOB Fax <br /> APN 21319016 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name JOHN G &TAMELA J KISST <br /> Title <br /> Day Phone 209-832-3077 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002917 New Account ID: <br /> Mail Invoices to Facility /4c)'J US Mail Invoices to: Owner / Facility / Account <br /> Account Name KISST D (Circle One) <br /> Account Balance as of 2/19/2015: $292.00 d�� S"A Si1tZcE+AtZ G <br /> j� (Circle One) <br /> ✓I I�GL �/W N ��� T K I� Transfer to Activetinactve <br /> Program/Element and Description / Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PR0525235 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2011 -GRADE A DAIRY PR0200023 EE0005362-NICHOLAS WIESEMAN Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0530980 EE0002646-THUY TRAN Active Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PR0530979 EE0002646-THUY TRAN Active Y N A Q D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532015 Inactive Y N A I D <br /> 4620-DAIRY- WATER SUPPLY WA0515616 EE0005362-NICHOLAS WIESEMAN Active 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,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 anctor Standards and State ancvor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: 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 /> RENS: —r'�) �\J I—I) r-- Date -Z 7 Account out: /4t Date 2/ ;�-:5/ I ; <br /> COMMENTS: <br /> NAC,T i VArr �I� 2-3 Z5 H AN k �� b I <br />