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Date run 2115/2013 2:39:46PR SAN X IUIN COUNTY ENVIRONMENTAL HEA i DEPARTMENT Report#5021 <br /> Run byPagel <br /> Facility Information as of 2/15/2013 <br /> Record S --Ir2 ft-iteria: Facility ID FA0016834 <br /> Make changes/corrections in RED ink. <br /> INFORMATIONCHANGE(date) <br /> 0@90P OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN 1 Fed Tax ID <br /> Owner ID OW0013675 5 ZB13 New Owner ID <br /> Owner Name BRUCE METTLER <br /> Owner DBA BRUCE METTLER E�+�li{(y4VM�NT <br /> Owner Address 17901 N CHERRY RD pEfr;11�1Y�SiIf1Cs <br /> LODI, CA 95240 <br /> Home Phone Not Specified ' <br /> Work/Business Phone Not Specified <br /> Mailing Address 17901 N CHERRY RD <br /> LODI, CA 95240 <br /> ALI— <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0016834 <br /> Facility Name BRUCE METTLER <br /> Location 17900 N CHERRY RD <br /> LODI, CA 95240 <br /> Phone 209-369-4905 x0 <br /> Mailing Address 17901 N CHERRY RD <br /> LODI, CA 95240 <br /> Care of <br /> Location Code Alt Phone <br /> $OS District Fax <br /> APN 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 AR0029716 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name BRUCE METTLER (circle One) <br /> Account Balance as of 2/15/2013: $53.00 <br /> (Circle One) <br /> ( Transfer to Activeflnactve <br /> P amlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958 HM-Farm Operations PR0525019 Active Y N A D <br /> G and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSlEHD 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 andlor Standards and State and/or <br /> Federal Laws <br /> APPLICANT'S SIGNATURE:r DateV_Z ! I. -3 <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date 1 ! <br /> Water System to be TRANSFERED Amount Paid Date 1 ! <br /> Payment Type Check Number Recei <br /> REHS- A&,64 v( w Datl'�2-- V <br /> 1 .-I [_ Account out: y Date /2-17-E 13 <br /> COMMENTS: <br />