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Date run 1/21/2011 10:58:58AI SAN 3 _UIN COUNTY ENVIRONMENTAL HE/ DEPARTMENT Report#5021 <br /> Run by 5290 <br /> Facility Information as of 1/21/2011 Paget <br /> Record Selection Criteria: Facility ID FA0017126 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0013967 New Owner ID <br /> Owner Name MIKE REGO <br /> Owner DBA MIKE REGO <br /> Owner Address 13222 N NEELY RD <br /> LODI, CA 95242 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address T x � <br /> LODI, CA 95242 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017126 <br /> Facility Name MIKE REGO <br /> Location 13579 N DEVRIES RD <br /> LODI, CA 95242 <br /> Phone 209-367-1382 x0 Q <br /> Mailing Address +a2,Q2-N-r�t1Et-)(-RD <br /> LODI, CA 95242 <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 05517032 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0030008 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name MIKE REGO (Circle One) <br /> Account Balance as of 1/21/2011: $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 PR0529601 EE0001422-ARIS CACAPIT Active Y N A I D <br /> 2223-AGRICULTURAL HAZ MAT STORAGE FACILPRO525311 Active Y N A I D <br /> 2830-AST FAC -SPCC EXEMPT PRO529600 EE0001422-ARIS CACAPIT Active,Exempt Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PR0532913 Active 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: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date /_ / Account out: Date / / 2-14 <br /> COMMENTS: <br /> ......... . <br /> \\eh-env\envision\reports\5021.rpt <br />