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Date inn 4/8/2015 2:35:53PM ,SAN JIN COUNTY ENVIRONMENTAL HEASIIEPARTM ENT Report 7/5021 <br /> Run by Pagel <br /> Facility Information as of 4/8/2015 <br /> Record Selection Criteria: Facility ID FA0022523 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0020051 New Owner ID <br /> Owner Name Frank D. Mills <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-631-1491 <br /> Mailing Address 4926 West Turner Road <br /> Lodi, CA 95242 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0022523 10482229 <br /> Facility Name Brack Tract Storage <br /> Location 13552 W Woodbridge Rd <br /> Lodi, CA 95242 <br /> Phone 209-631-1491 x <br /> Mailing Address 4926 West Turner Road <br /> Lodi, CA 95242 <br /> Care of Frank D. Mills <br /> Location Code Alt Phone <br /> BOS 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 AR0041203 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility I Account <br /> Account Name Brack Tract Storage (circle One) <br /> Account Balance as of 4/8/2015: $0.00 <br /> (Circle One) <br /> Transfer to Active/InacNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1rogr8 <br /> 4920 HMBP-Common Materials PR0539406 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: ],the undersigned owner,operator or agent of same,acknowledge that all site,anNor project specific,PHS/EHO 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 and'or Standards and State and/or <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Paymentp Check Number Rao 'v y <br /> REHS: MQ Ste- Date / /� Account out: Date <br /> COMMENTS: <br />