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Date run 2/3/2011 4:46:35PM SAN JO' ^UIN COUNTY ENVIRONMENTAL HEAD —4 DEPARTMENT Report#5021 <br /> Run by 1273 Pagel <br /> Facility Information as of 2/3/20 , <br /> Record Selection Criteria: Facility ID FA0009569 <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 OW0007124 Case Number: H01367 New Owner ID <br /> Owner Name GEWEKE, LARRY <br /> Owner DBA <br /> Owner Address 102 HANSEN ST <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-344-6500 <br /> Mailing Address PO BOX 1210 <br /> LODI, CA 95241 <br /> Care of GEWEKE, LARRY <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0009569 <br /> Facility Name GEWEKE RV <br /> Location 248 E KETTLEMAN LN <br /> LODI, CA 95240 <br /> Phone 209-334-0987 <br /> Mailing Address PO BOX 1210 <br /> LODI, CA 95241 <br /> Care of <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 057-160-10 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 AR0016569 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name GEWEKE, LARRY (Circle One) <br /> Account Balance as of 2/3/2011: $24.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PRO513907 EE0001422-ARIS CACAPIT Inactive X N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHOR IZATIOIPRO511857 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-IDES PR0519732 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0501751 EE0004636-GARRETT BACKUS Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR1PR0509569 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATI\PR0515595 EE0001422-ARIS CACAPIT Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PR0533162 Inactive 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: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Receiv <br /> REHS: �Z Date / / tl Account out: Date <br /> COMMENTS: /I I �iY�s J- - , A <br /> \\e h-env\envision\reports\5021.rpt <br />