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Date run 2/11/2011 1:55:59PN SAN JC 'UIN COUNTY ENVIRONMENTAL HEA" "I DEPARTMENT Report #5021 Run by Pagel Facility Information as of 2/11/2011 Record Selection Criteria: Facility ID FA0009310 OWNER FILE INFORMATION owner ID OW0007310 Case Number: H03035 Owner Name D & C WORTLEY 1995 FAMILY TRUS Owner DBA DSW AG INC Owner Address 15910 N DAVIS RD EE0000000 - HAZ MAT SJC OES LODI, CA 952429221 Home Phone Not Specified Work/Business Phone 209-369-2914 Mailing Address PO BOX 311 Care of LODI, CA 952410311 Care of 99 - UNINCORPORATED A FACILITY FILE INFORMATION Facility ID FA0009310 Facility Name DSW AG INC Location 15910 N DAVIS RD EE0000000 - HAZ MAT SJC OES LODI, CA 95242 Phone 209-369-2914 x0 Mailing Address PO BOX 311 Active LODI, CA 952410311 Care of 2399 - UNIFIED PROGRAM FAC STATE SURCHARPR0509310 Location Code 99 - UNINCORPORATED A BOS District 004 - VOGEL, KEN APN 01703001 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone 209-369-2914 Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0016310 Mail Invoices to Facility Account Name DSW AG INC Account Balance as of 2/11/2011: $637.00 Program/Element and Description Record ID Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : Alt Phone Fax Entail: i 6 Ttcl� I e." Q:kl) �i2'1 I l �-7 New Account ID: Mail Invoices to: Owner / Employee ID and Name Status Facility / Account (Circle One) (Circle One) Transfer to Active/Inactve New Owner? Delete 2220 - SM HW GEN <5 TONS/YR PR0527709 EE0001422 - ARIS CACAPIT Active Y N A I D 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO511598 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D 2244 - PACT TRANSFER RECORD - OES PR0519537 EE0000000 - HAZ MAT SJC OES Active Y N A I D 2399 - UNIFIED PROGRAM FAC STATE SURCHARPR0509310 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D 2830'= AST FAC - SPCC EXEMPT PR0527710 EE0001422 - ARIS CACAPIT Active,-xowrp - Y N A I D C- ELECTRONIC REPORTING SURCHARGE PR0533873 Active Y N A I D 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 facility or activity will be billed to the party identified as the OWNER on this form. I also State and/or Federal Laws. certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standardsa_ nd ,' T_ a'f4N�T'S SIGNATURE: Date Program Records to be TRANSFERED: " $25.00 = Water System to be TRANSFERED: Payment Type A Check Number REHS: Date COMMENTS: \\eh-env\envision\reports\5021. rpt Amount Paid Date Amount Paid Date — Account out: Rece'v bDate