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Date run 1/27/2010 12:44:24PI SAN JOA"UIN COUNTY ENVIRONMENTAL HEAT"i DEPARTMENT Report#5021 <br /> Run by 5290 Pagel <br /> A./ Facility information as of 1/27/2tw4 <br /> Record Selection Criteria: Facility ID FA0017440 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN I Fed Tax ID <br /> Owner ID OW0014281 New Owner ID : <br /> Owner Name KATHERINE KELLY <br /> Owner DBA KATHERINE KELLY <br /> Owner Address 26565 COUNTY RD 97D <br /> DAVIS, CA 95616 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 26565 COUNTY RD 97D <br /> DAVIS, CA 95616 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017440 <br /> Facility Name KATHERINE KELLY <br /> Location 3951 W SARGENT <br /> LODI, CA 95240 <br /> Phone 805-595-2646 x0 <br /> Mailing Address 26565 COUNTY RD 97D <br /> DAVIS, CA 95616 <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District p04 -VOGEL, KEN Fax <br /> APN 02515025 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 AR0030322 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner I Facility / Account <br /> Account Name KATHERINE KELLY (Circle one) <br /> Account Balance as of 112712010: $0.00 <br /> (Circle One) <br /> Trensferto Activelinaclve <br /> ProgramlEiement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONSNR PRO529578 EE0001422-ARIS CACAPIT Active Y N A I D <br /> 2223-AGRICULTURAL HAZ MAT STORAGE FACILPRO525625 Active Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0529577 EE0001422-AR IS CACAPIT Aclive,Exempt 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,PHSIEHD 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 andlor Federal Laws. <br /> APPLICANT'S SIGNATURE: Dale 1 / <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date ! / <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date I I <br /> Payment Type Check Number Received by <br /> RENS: Date 1 I Account out: Date l1 -2'7/ /0 <br /> COMMENTS- <br /> pt v <br /> Ileh-envlenvisionlreports15021.rpt PPT 4_ <br />