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'Date run 17/2008 7:55:17AK SAN JUUIN.COUNTY ENVIRONMENTAL HE/ "IR DEPARTMENT Report#5021 <br /> Run by; r: '� Pagel <br /> Facility Information as of-6117/20t� <br /> Record Selection Criteria: Facility ID FA0010218 <br /> Make changeslcorrections in RED ink or pencil. <br /> INFORMATION CHANGE(date).QI1)OD 54,1_0 <br /> 1 OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION �. S5N!Fed Tax Ip <br /> Owner ID OW0008218 Case Number: H07364 N Owne ID <br /> Owner Name �— <br /> Owner DBA <br /> Owner Address gaQ_BE)X_4pg-iL <br /> p p <br /> Home Phone <br /> Work/Business Phone Not Specified azo Q u,Jq Q! <br /> Mailing Address -p15rg15X-1-0t);JL- [[ <br /> Care of <br /> FACILITY.FILE INFORMATION y� <br /> Facility ID FA0010218 11A <br /> Facility Name <br /> ' Location 1123 E VINE ST - <br /> LODI, CA 95240 <br /> Phone <br /> Mailing Address Pl rg 17Z /'�/� <br /> Wil _�-- / S 77 <br /> Care of <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 04915006 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> r <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017218 New Account ID: <br /> Mail Invoices to Facility 1 Mail.Invoi to: Owner 1 Facility 1 Account <br /> Account Name, /" (Circle One) <br /> Account Balance as of 6/17/2008: $0.00 <br /> (Circle One) <br /> Transferto Activellnactve <br /> Program/Element and Description Record ID Employee ID and.Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0514236 EE0001422-ARIS CACAPIT Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO]PRO512506 EE0000000-HAZ MAT SJC IDES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-IDES PRO520164 EE0000000-HAZ MAT SJC IDES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARiPR0510218 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2836-AST FAC>I=100 M+1 GAL CUMULATIVE PR0526955 ;EE0001422-ARIS CACAPIT Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0524827 EE5555555-Garrett Alias-Backus 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 spec,PHSlEHD 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 Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / ! <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 Receiv <br /> REHS: Date 1 / Account out: Date / 1. <br /> COMMENTS: <br /> CJ <br />' llphs-ehsgl-ntlappslenvisionslreports15021.rpt <br />