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Date run 10/8/2018 11:56:55AI SANJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Fakility Information as of 10/8/2018 Pagel <br /> Record Selection Criteria: Facility ID FA0017151 <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 OW0013992 New Owner ID <br /> Owner Name HWY 12 FARMS INC <br /> Owner DBA HWY 12 FARMS INC <br /> Owner Address 11961 W HWY 12 <br /> LOD], CA 95242 <br /> Home Phone Not Specified d <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 FA001 7151 10185975 <br /> Facility Name HWY 12 FARMS INC <br /> Location 11961 W HWY 12 <br /> LODI, CA 95242 <br /> Phone 209-483-5885 XO rl/ -r—W <br /> Mailing Address 3840 BROOK VALLEY CIR <br /> ',�TO�CKTON, CA 95219 o I L <br /> care of Michael Scriven <br /> Location Code <br /> Phone V <br /> BOS District Fax <br /> APN 02507001 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 AR0030033 New Account ID: <br /> Mail Invoices to Account M a ii III I no es to: Owner / Facility Account <br /> Account Name HWY 12 FARMS INC (Circle One) <br /> Account Balance as of 10/8/2018-. $190.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Prograrn/Element and Description Record ID Employee to and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PR0525336 EE0002670-MUNIAPPA NAIDU Active Y N A I D <br /> 2221 -USED OIL ONLY-<5 TONS/YR PR0539061 EE0000030-AARON HANG Active Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PR0530511 EE0000030-AARON HANG Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534144 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,PHSIEHD 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 ancl/or Standards and State andfor <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. Date. Account out: Date <br /> COMMENTS: <br /> In oice#: <br /> VM <br />