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Date run 3/7/2008 10:52:00AM SAN '`)UIN COUNTY ENVIRONMENTAL HE -—q DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/7/2vu- <br /> Record Selection Criteria: Facility ID FA0009875 <br /> t Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) ?-'7 fU <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0007875 Case Number: H05705 New Owner ID <br /> Owner Name FORD CONSTRUCTION <br /> Owner DBA FORD CONST CO INC <br /> Owner Address 639 E LOCKEFORD ST <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-333-1116 <br /> Mailing Address 639 E LOCKEFORD ST <br /> LODI, CA 95240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009875 <br /> Facility Name FORD CONST CO INC <br /> Location 500 N CLUFF AVE <br /> LODI, CA 95240 <br /> Phone 209-333-1116 <br /> Mailing Address 639 E LOCKEFORD ST <br /> LODI, CA 95240 <br /> Care of <br /> Location Code 02 - LODI APN:049-080-55 <br /> BOS District 004-VOGEL, KEN SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016875 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name FORD CONST CO INC (Circle One) <br /> Account Balance as of 3/7/2008: $0.00 <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 PRO514074 EE0001422-ARIS CACAPIT Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPR0512163 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0519931 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPR0509875 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> AST FAC>/=100 M+ 1 GAL CUMULATIVE PR0516579 EE0001422-ARIS CACAPIT Active Y N A I D <br /> r <br /> WASTE TIRE SITE-EXEMPT PR0524531 EE0000060-JENNIFER FRASE Inactive Y N A I D <br /> 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 /> r 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 /> d/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: *$372.00= Amount Paid Date <br /> Payment Type !n���__ Check Number Re ei a by <br /> REHS: c. u�� Date / -7 / Account out: Date / <br /> COMMENTS: <br /> \\phs-ehsq I-nt\apps\envisions\reports\5021.rpt <br />