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Date run 10/16/2018 11:45:201 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/16/2018 <br /> Record Selection Criteria: Facility ID FA0017256 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0014097 New Owner ID : <br /> Owner Name MARIO PODESTA jC Q U-e-tcA� fWtS . <br /> Owner DBA MARIO PODESTA <br /> Owner Address 14655 E HWY 26 <br /> LINDEN, CA 95236 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 14655 E HWY 26 <br /> LINDEN, CA 95236 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017256 10186157 <br /> Facility Name MARJAC WALNUTS <br /> Location 14655 E HWY 26 <br /> LINDEN, CA 95236 <br /> Phone 209-931-4596 x0 <br /> Mailing Address 14655 E HWY 26 <br /> LINDEN, CA 95236 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 09106002 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0030138 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name MARIO PODESTA / c-A� 'klAtA (Circle One) <br /> Account Balance as of 10/16/2018: $101.00 Vv <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PR0525441 EE0002670-MUNIAPPA NAIDU Active Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PR0530265 EE0000027-CINDY VO Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533311 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror 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 andror <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 0 <br /> EHD Staff: Date / / Account out: t43 Date <br /> COMMENTS: <br /> Invoice#: <br />