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Date run 1/28/2011 11:34:40AI SAN JO' -"UIN COUNTY ENVIRONMENTAL HEA- '-I DEPARTMENT Report#5021 Run by 5290 Pagel Facility Information as of 1/28/20-11 Record Selection Criteria: Facility ID FA0017004 OWNER FILE INFORMATION Owner ID OW0013845 Owner Name JAMES COTTA VINEYARDS Owner DBA JAMES COTTA VINEYARDS Owner Address 10301 W PELTIER RD Program/Element and Description Record ID LODI, CA 95242 Home Phone Not Specified Work/Business Phone Not Specified Mailing Address 10301 W PELTIER RD 2223 - AGRICULTURAL HAZ MAT STORAGE FACILPRO525189 LODI, CA 95242 Care of I D FACILITY FILE INFORMATION Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID : New Owner ID : 3�JA) 0 Facility ID FA0017004 QV v20(o 9�j Facility Name JAMES COTTA VINEYARDS Location 10301 W PELTIER RD LorD r /1 LODI, CA 95242 Q Phone 209-329-0172 x0 Mailing Address 10301 W PELTIER RD 0 LODI, CA 95242} Care of Location Code 99 - UNINCORPORATED P BOS District 004 - VOGEL, KEN APN 01104003 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0029886 Mail Invoices to Owner Account Name JAMES COTTA VINEYARDS Account Balance as of 1/28/2011: $0.00 Alt Phone Fax EMail : ASA P/'-- -fir 2zao A,�- P'0 3L-/- New Account ID: : Mail Invoices to: Owner / Facility / Account (Circle One) APPLICANT'S SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number $25.00 = Amount Paid _ Amount Paid Date Date Date Receivgd ay REHS: Date / ! Account out: Date COMMENTS: \\eh-env\envision\reports\5021.rpt "v �D fM-OV� IT (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 2220 - SM HW GEN <5 TONS/YR PRO529676EE0001422 - ARIS CACAP%T Active Y N A I D 2223 - AGRICULTURAL HAZ MAT STORAGE FACILPRO525189 r"V& -� %lam ctiive �Y� N A I D 2830 - AST FAC - SPCC EXEMPT PR0529675 EE0001422 - ARIS CACAPIT-� %1Qtl /�,p[ r� I �""r N A I D 4740 - WASTE TIRE SITE - EXEMPT PRO535216 EE0002620 - ALFONSO ARAMBULA Active Y N A eD ERSC - ELECTRONIC REPORTING SURCHARGE PR0532946 Active Y N A 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 certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number $25.00 = Amount Paid _ Amount Paid Date Date Date Receivgd ay REHS: Date / ! Account out: Date COMMENTS: \\eh-env\envision\reports\5021.rpt "v �D fM-OV� IT