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Date run 2/4/2008 11:36:26AM <br />Run by <br />Record Selection Criteria: Facility ID <br />OWNER FILE INFORMATION <br />SAN A OUIN COUNT I' ENVIRONMENTAL HF " TH DEPARTMENT Report #5021 <br />Facility Information as of 2/4/iv.,., � fn*'O� I t- W <br />FA0009310 <br />Owner ID OW0007310 Case Number: H03035 <br />Owner Name <br />D & C WORTLEY 1995 FAMILY TRUS <br />Owner DBA <br />DSW AG INC <br />Owner Address <br />15910 N DAVIS RD <br />LODI, CA 952429221 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-369-2914 <br />Mailing Address <br />PO BOX 311 <br />Care of <br />LODI, CA 952410311 <br />Care of <br />99 - UNINCORPORATED AREA <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0009310 <br />Facility Name <br />DSW AG INC <br />Location <br />15910 N DAVIS RD <br />LODI, CA 95242 <br />Phone <br />209-369-2914 <br />Mailing Address <br />PO BOX 311 <br />Date <br />LODI, CA 952410311 <br />Care of <br />" $372.00 = <br />Location Code <br />99 - UNINCORPORATED AREA <br />BOS District <br />004 - VOGEL, KEN <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0016310 <br />Mail Invoices to Owner <br />Account Name D & C WORTLEY 1995 FAMILY TRUS <br />Account Balance as of 2/4/2008: $399.00 <br />Program/Element and Description Record ID Employee ID and Name <br />Make changesicorrections in RED ink or pencil. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />New Owner ID : <br />APN:017-030-01 <br />SIC Code:9600 <br />New Account 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 />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATIOrPR0511598 EE0000000 - HAZ MAT SJC IDES Inactive Y N A I D <br />2244 - PACT TRANSFER RECORD - OES PR0519537 EE0000000 - HAZ MAT SJC OES Active Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHAR43R0509310 EE0000000 - HAZ MAT SJC OES 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 specific, PHS/EHD 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 and/or Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: <br />' $20.00 = <br />Amount Paid <br />Date <br />Water System to be TRANSFERED: <br />" $372.00 = <br />Amount Paid <br />Date <br />Payment Type <br />Check Number <br />Receiv <br />RENS: l� (In <br />Date <br />/ / C Account out: <br />Date <br />COMMENTS: <br />V�-04 <br />Ct <br />\\phs-ehsql-nt\apps\envisions\reports\5021. rpt <br />