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Date run 7/2/2008 4:01:43PM SAID 1QUIN COUNTY ENVIRONMENTAL H" ',TH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 7/2/2u08 <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 />Phone <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 <br />FA0006280 <br />Facility Name <br />DONALD S WORTLEY <br />Location <br />15910 N DAVIS RD <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 7/2/2008: $0.00 <br />Program/Element and Description <br />Record ID 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 Owner ID : <br />Alt Phone <br />Fax <br />EMail <br />New Account ID: <br />Mail Invoices to: Owner / <br />Status <br />Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />New Owner? Delete <br />2335 - FARM UST #3 FACILITY - obsolete PR0504676 EE0004636 - GARRETT BACKUS Inactive Y N A I D <br />83 AST FAC >/=100 M + 1 GAL CUMULATIVE PR0515787 EE0001422 - ARIS CACAPIT Inactive Y N A I D <br />LBILLIYNGnd 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 />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 />or Federal Laws. <br />z83b <br />APPLICANT'S SIGNATURE: Date <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 />* $20.00 = <br />* $372.00 = <br />Date <br />Amount Paid Date <br />Amount Paid Date <br />Rece' y <br />Account out: Date --7—/ / D� <br />