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Date run 1/27/2011 11:13:53AI SAN JOf'_'VIN COUNTY ENVIRONMENTAL HEAL ­4 DEPARTMENT Report#5021 <br /> Run by 5290 Pagel <br /> Facility information as of 1127120 <br /> Record Selection Criteria: Facility ID FA0016847 <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 OW0013688 New Owner ID <br /> Owner Name JERRY D METTLER <br /> Owner DBA JERRY D METTLER <br /> Owner Address 16441 N LOCUST TREE RD <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 16441 N LOCUST TREE RD <br /> LODI, CA 95240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0016847 <br /> Facility Name JERRY D METTLER <br /> Location 16475 N LOCUST TREE RD I I.P y! L7o L(tSt' -a e_1 <br /> LODI, CA 95240 <br /> Phone 209-334-5686 x0 <br /> Mailing Address 16441 N LOCUST TREE RD <br /> LODI, CA 95240 <br /> Care of <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> Bos District 004 -VOGEL, KEN Fax <br /> APN 05113075 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 AR0029729 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner 1 Facility / Account <br /> Account Name JERRY D METTLER (Circle One) <br /> Account Balance as of 112712011: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2223-AGRICULTURAL HAZ MAT STORAGE FACILPRO525032 Active Y N A I D <br /> '.2840-AST EXEMPT FAC c 1,320 GAL PR0529486 EE0000753-WILLY NG Active,Exempt Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PRO532772 Active 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,PHSlEHD hourly charges associated Mth this <br /> facility or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations wiSl be performed in accordance with all applicable Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date ! 1 <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date I ! <br /> Water System to be TRANSFERED: Amount Paid Date I ! <br /> Payment Type Check Number Received by <br /> RENS: Date I 1 Account out: 6 Date IL-�A- 1 <br /> COMMENTS: <br /> lleh-envlenvisionlreports15021.rpt <br />