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Dsteron' _ 43/25/2010 2:28:39PA SAN J IUIN COUNTY ENVIRONMENTAL HE. DEPARTMENT Report 45021 <br /> Run by �/ Pagel <br /> Facility Information as of 3/25/2010 <br /> Record Selection Criteria: Facility ID FA0009710 <br /> Wake changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN 1 Fed Tax ID : <br /> Owner ID OW0007710 Case Number: H05197 New Owner ID <br /> Owner Name �� N <br /> Owner DBA $ r I 1 r <br /> Owner Address E KETTLEMAN LN / <br /> LODI, CA 95240 <br /> Home Phone 209-399-SW 071M --314 <br /> Work/Business Phone Not Specified <br /> Mailing Address ME KETTLEMAN LN <br /> LODI, CA 95240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009710 <br /> Facility Name r <br /> Location 325 E KETTLEMAN LN <br /> LODI, CA 95240 <br /> Phone 209-369,SW 3 G <br /> Mailing Address 325 E KETTLEMAN LN <br /> LODI, CA 95240 <br /> Care of <br /> Location Code 02 -LODI Alt Phone 91ab -*lLf , <br /> BOS District 004-VOGEL, KEN Fax _ <br /> APN 04727016 EMail: mgt, ?>d C wJ_tA" <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title UN�+ - <br /> Day Phone 4-6'�O5 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016710 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility 1 Account <br /> Account Name KEN GINI (circle one) <br /> Account Balance as of 3125/2010: $0.00 <br /> (Circle One) <br /> Transfer to ActivellnaMe <br /> Program/Element and Description Record 1D Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONSIYR PRO513999 EE0001422-ARIS CACAPIT Inactive Y N (±.> I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO511998 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PRO519814 EE0000000-HAZ MAT SJC OES Inactive Y N 0 I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPR0509710 EE0000000-HAZ MAT SJC IDES Inactive Y N A I D <br /> 474 �-WASTE TIRE SITE-EXEMPT yr'� R0055223r2/49 ��ryrEE5555555-Garrett Alias-Backus �,�It}nactive Y N 1 D <br /> G a�COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,o dr for or agent of some,acknowledge that all site,an&o projy4lc,PHS/EHD hourly charges aced 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 Ordinate Codes and/or Standards and <br /> State andlor Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: "$20.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date 1 I Account out: _(, Date �✓ 1-A-ZP 1� <br /> COMMENTS: <br /> Ueh-envlenvisionlreports15021.rpt <br />