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Date run 10/26/2018 4:00:48P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by ti Pagel <br /> Facility Information as of 10/26/2018 <br /> Record Selection Criteria: Facility ID FA0017151 <br /> Make changestcorrections 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 OW0013992 New Owner ID <br /> Owner Name HWY 12 FARMS INC <br /> Owner DBA HWY 12 FARMS INC <br /> OwnerAddress 11961 W HWY 12 <br /> LODI, CA 95242 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-472-1313 <br /> Mailing Address 3840 BROOK VALLEY CIR <br /> STOCKTON, CA 95219 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017151 10185975 <br /> Facility Name HWY 12 FARMS INC c!C COY <br /> Location 11961 W HWY 12 A- <br /> LODI, CA 95242 G Iro CX gSO,;O <br /> Phone 209-483-5885 x0 NO 1 G <br /> Mailing Address 3840 BROOK VALLEY CIR 1020 Vir <br /> STOCKTON, CA 95219 :I �S ,�O <br /> Care of M' <br /> Location Code It Phone <br /> BOS District /Fax <br /> APN 02507001 Mail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0030033 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name HWY 12 FARMS INC (Circle One) <br /> Account Balance as of 10/26/2018: $190.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? elet <br /> 1958-HM-Farm Operations PRO525336 EE0002670-MUNIAPPA NAIDU Active Y N <br /> . 2221 -USED OIL ONLY-<5 TONS/YR PR0539061 EE0000030-AARON HANG Active Y N 2830-AST FAC -SPCC EXEMPT PR0530511 EE0000030-AARON HANG Active Y N qy ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO534144 InactivE Y N A <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 and/or Standards and State ancitor <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 /> EHD Staff: �C� 1NC't�Gc'b6+ Date /4 / dC / %� Account out: Date i'&, <br /> COMMENTS: / " r ' <br /> gLcSP,^ o� Si tP. 10 JZ /P 4"e' /nSrY4•T�c>Yt SCSYrlP '�G tP Invoice#: <br />