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Date run 2/28/2013 9:59:06AR SAN JOIN COUNTY ENVIRONMENTAL HEAV DEPARTMENT Report 95021 <br /> Run by Pagel <br /> Facility Information as of 2/28/20 <br /> Record Selection Criteria: Facility ID FA0000480 <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 OW0000396 New Owner'^ <br /> Owner Name BENIGNO, BEVERLY <br /> Owner DBA ROCKY'S RESTAURANT <br /> Owner Address 14659 N THORNTON RD <br /> LODI, CA 95242 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 2601 <br /> LODI, CA 95241 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0000480 <br /> Facility Name ROCKYS RESTAURANT <br /> Location 14659 N THORNTON RD <br /> LODI, CA 9524 <br /> Phone 209-369-1973 �O <br /> Mailing Address PO BOX 2601 <br /> LODI. CA 95241 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 05515025 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 AR0000479 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name ROCKYS RESTAURANT (Circle One) <br /> Account Balance as of 2/28/2013: 44e0-010h-a r <br /> (Circle One) <br /> Transfer to Active4nadve <br /> PrograMElemenl and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1626-RESTAURANT/BAR 101 +SEATS PRO160165 EE0005362-NICHOLAS WIESEMAN Active Y N A I D <br /> 1920-HMBP-Common Materials PR0521616 EE0008709-JAMIE DE LA ROSA Active Y N A C) D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0533581 Inactive Y N A 1 0 <br /> 4633-TNC WATER SYSTEM WA0461247 EE0005838-ADRIENNE ELLSAESSEInactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersign$d owner,operator or agent of same,acknowledge that all site,andlor project specific,PMS/EI-D hourly charges associated with this facilay <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 andfor Standards and Slate andor <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 Crhheck Number Receiv <br /> ,REtiS! c )CAIN.\ P 7Q�� Pate Z_/_Z2? 1J'2 <br /> _ Account out: Date <br /> TS: <br />