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Date run 1/8/2010 9:18:35AM SAN JO'A )UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 1/8/20.... <br /> Record Selection Criteria: Facility ID FA0017846 <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 OW0002258 New Owner ID <br /> Owner Name VICTORIA ISLAND FARMS <br /> Owner DBA <br /> Owner Address PO BOX 87 <br /> HOLT, CA 95234 <br /> Home Phone 209-465-5600 RICKY CANEPA aim <br /> Work/Business Phone 209-465-5608 <br /> Mailing Address PO BOX 87 <br /> HOLT, CA 95234 4 <br /> Care of NICHOLS, GRAYDON i TIIn� T oIA �'*k �o Tiles PTOFIR�1fr`ffCR, jl rv" <br /> FACILITY FILE INFORMATION Water Well Drilling•Test Holes• Free Estimates• Pumps <br /> Facility ID FA0017846 Installation and Service• Electronic Water Locator(WAD) <br /> Facility Name VICTORIA ISLAND FARMS Lic. No. 425749 <br /> Location 21000 W HWY 4 (209)532-1136 13760 Mono Way <br /> HOLT, CA 95234 FAX(209)532-4819 Sonora,CA 95370 <br /> Phone 209-465-5600 <br /> Mailing Address PO BOX 87 <br /> HOLT, CA 95234 <br /> Care of NICHOLS, GRAYDON <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 003 - BESTOLARIDES Fax <br /> APN 12919030 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name JAMES JERKOVICH <br /> Title <br /> Day Phone 209-465-5600 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0031217 S S New Account ID: <br /> Mail Invoices to Account C k Mail Invoices to: Owner / Facility / Account <br /> Account Name 1 b Q '�A o W (circle one> <br /> Account Balance as of 1/8/2010: $0.00 <br /> S 3 (Gree One) <br /> v r Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PR0526373 EE0006219-LORI DUNCAN 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 <br /> facility 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 Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid 3q S Date / $ / Q <br /> Water System to be TRANSFERED: *$372.00= Amount Paid Date <br /> Payment Type Check Number Received by L .0 r <br /> REHS: -r�wt� Date�!_�/ /G Account out: Date \ l 'rs \ b <br /> COMMENTS: <br /> Lw leo-7`f <br /> \\eh-env\envision\reports\5021.rpt <br />