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Date run , Rs1212008 3:08:25PN SAN QUIN COUNTY ENVIRONMENTAL HL FH DEPARTMENT Report#5021 <br />Run by y Pagel <br />Facility Information as of 6/12/2008 <br />Record Selection Criteria: Facility ID FA0006280 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0005006 <br />Owner Name <br />WORTLEY, DONALD S <br />Owner DBA <br />DONALD S WORTLEY <br />Owner Address <br />15910 N DAVIS RD <br />LODI, CA 95240 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />15910 N DAVIS ROAD <br />LODI, CA 95240 <br />Care of <br />DONALD S WORTLEY <br />FACILITY FILE INFORMATION <br />Facility ID FA0006280 <br />Facility Name <br />Location 15910 N DAVIS f <br />LODI, CA 95240 <br />Phone <br />Mailing Address 15910 N DAVIS RD <br />LODI, CA 95240 <br />Care of DONALD S WORTLEY <br />Location Code 99 - UNINCORPORATED P <br />BOS District 004 - VOGEL, KEN <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name DONALD S. WORTLEY <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0007471 <br />Mail Invoices to Facility <br />Account Name DONALD S WORTLEY <br />Account Balance as of 6/12/2008: $0.00 <br />Program/Element and Description Record ID <br />Employee ID and Name <br />Make changes/corrections in RED ink or pencil. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN /,Fed Tax ID <br />New .ID <br />Alt Phone <br />Fax <br />EMail : <br />NewAccount ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Status New Owner? Delete <br />2335 - FARM UST #3 FACILITY - obsolete PR0504676 EE0004636 - GARRETT BACKUS Inactive Y N A I D <br />2836 -AST FAC >/=100 M + 1 GAL CUMULATIVE PR0515787 EE0001422 - ARIS CACAPIT Active Y N A ? PedD <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges assoith 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 and/or Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />REHS: <br />COMMENTS: <br />\\phs-ehsql-nt\apps\envisions\reports\5021. rpt <br />Date <br />' $20.00 = Amount Paid Date <br />$372.00 = Amount Paid Date <br />Receiv <br />Date / / Account out: Date <br />