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Date run 2/13/2013 2:4039PK SAN JC UIN COUNTY ENVIRONMENTAL, HEA' I DEPARTMENT Report#5021 <br /> Run by .\/ — Pagel <br /> Facility Information as of 2/13/2013 <br /> Record Selection Criteria: Facility ID FA0009891 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN I Fed Tax ID <br /> Owner ID OW0007891 Case Number H05739 New Owner ID <br /> Owner Name HUESTIS, MIKE <br /> Owner DBA <br /> Owner Address 91 S KELLY ST <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-334-1877 <br /> Mailing Address 91 KELLY ST <br /> LODI, CA 95240 <br /> Care of HUESTIS, MIKE <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009891 <br /> Facility Name OUTDOOR POWER EQUIPMENT PLUS <br /> Location 91 S KELLY ST <br /> LODI, CA 95240 <br /> Phone 209-334-1877 <br /> Mailing Address 91 S KELLY ST <br /> LODI, CA 95240 <br /> Care of HUESTIS, MIKE <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 04906019 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016891 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner I Facility I Account <br /> Account Name OUTDOO ER EQUIPMENT PLUS (circleOne> <br /> Account Balance as of 2/13/2013' $120. <br /> �`-��_ (Circle One) <br /> Transfer to Activellnactve <br /> Element and Description Record ID Employee ID and dame Status New Owner? Delete <br /> 1920- `MBP-Common Materials PRO512179 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 0-SM HW GEN 5 TONS/YR PR0514086 EE0001422-ARIS CACAPIT Inactive Y N A t D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0509891 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. 1,the undersigned owner.,operator or agent of same,acknowledge that all site,andtor 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 andlor Standards and State andtor <br /> FederaV Laws. <br /> APPLICANT'S SIGNATURE. Date ! I <br /> Program Records to be TRANSFERED: *$25.00- Amount Paid Date f ! <br /> Water System to be TRANSFERED: Amount Paid Date I ! <br /> Payment Ty e Check Number Received by <br /> �r. r - Date I i z Account out: Date 2 ! 7 f l <br /> E S: <br />