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Date run 9/9/2009 10:58:57AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEAT 'sI DEPARTMENT Report#5021 <br /> Run by ' Pagel <br /> Facility Information as of 9/9/21l <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 <br /> Work/Business Phone 209-465-5608 <br /> Mailing Address PO BOX 87 <br /> HOLT, CA 95234 <br /> Care of NICHOLS, GRAYDON <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017846 -1/01101 <br /> Facility Name VICTORIA ISLAND FARMS <br /> Location 21000 W HWY 4 <br /> HOLT, CA 95234 / 5 <br /> Phone 209-465-5600 y� <br /> Mailing Address PO BOX 87 0c <br /> HOLT, CA 95234 l / <br /> Care of NICHOLS, GRAYDON <br /> Location Code 99- UNINCORPORATED P l <br /> Bos District 003- BESTOLARIDES <br /> APN 12919030 Vl(G l ti <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 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name VICTORIA ISLAND FARMS (Circle One) <br /> Account Balance as of 9/9/2009: $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 /> 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 Date <br /> Water System to be TRANSFERED: *$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />