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Date run 21:18/2014 8:48:04AI% SAN JC UIN COUNTY ENVIRONMENTAL HEA' DEPARTMENT Report#5021 <br /> Rin by 1273 Pagel <br /> Facility Information as of 2/18/2014 <br /> Record Selection Criteria: Facility ID FA0017406 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0014247 New Owner ID <br /> Owner Name HAL ROBERTSON FARMS LLC <br /> Owner DBA HAL ROBERTSON FARMS LLC <br /> Owner Address 27337 S BANTA RD <br /> TRACY, CA 95304 _ <br /> Home Phone Not Specified— — a <br /> Work/Business Phone Not Specified <br /> Mailing Address 27337 S BANTA RD <br /> TRACY, CA 95304 ( <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017406 10,186,403 <br /> Facility Name HAL ROBERTSON FARMS LLC <br /> Location 1801 W LINNE RD <br /> TRACY, CA 95304 <br /> Phone 209-835-0542 x0 <br /> Mailing Address 27337 S BANTA RD <br /> TRACY, CA 95304 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 005 - ELLIOTT, BOB Fax <br /> APN 23921007 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 AR0030288 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name HAL ROBERTSON FARMS LLC (Circle One) <br /> Account Balance as of 2/18/2014: $0.00 <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 PR0525591 Active Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PR0529359 EE0009001 -ELENA MANZO Active,/ Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534270 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,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 and/or Standards and State and/or <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 R t by <br /> RENS: Date / / Account out: Date <br /> COMMENTS: <br />