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Date run 12/1/2008 1:52:50PN SAN JO"')UIN COUNTY ENVIRONMENTAL HEA—" DEPARTMENT Report#5021 Run by Pagel Facility Information as of 12/1/2(,-o Record Selection Criteria: Facility ID FA0003429 OWNER FILE INFORMATION Owner ID OW0002552 Case Number Owner Name M Owner DBA LODI HOME DAIRY Owner Address 2300 W ARMSTRONG RQ BOS District LODI, CA 95242 Home Phone Not Specified Work/Business Phone 209-368-9438 Mailing Address 2300 W ARMSTRONG RD LODI, CA 95242 Care of $ FACILITY FILE INFORMATION Facility ID FA0003429 Facility Name LODI HOME DAIRY Location 2300 W ARMSTRONG RD LODI, CA 95242 Phone 209-368-9438 Mailing Address 2300 W ARMSTRONG RD EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone 209-368-94--aB Night Phone 209-36&--9473$ ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0003006 Mail Invoices to Facility Account Name LODI HOME DAIRY Account Balance as of 12/1/2008: $0.00 Program/Element and Description 2011 - GRADE A DAIRY Make changes/corrections in RED ink or pencil. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID 002447 New Owner ID : A lig S LIA 7 ON fiviP Alt Phone Fax EMail : 3 Record ID Employee ID and Name New Account ID: Mail Invoices to: Owner / Status PR0200098 EE0004589 - KADEANNE LINHARES Inactive Facility / Account (Circle One) (Circle One) Transfer to Active/Inactve New Owner? Delete 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 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: Date Program Records to be TRANSFERED: ' $20.00 = Amount Paid Date Water System to be TRANSFERED: ' $372.00 = Amount Paid Date Payment Type _ heck Number Receiv RENS: ' Date Zi I / Account out: Date O / /"P COMMENTS: \\phs-ehsql-nt\apps\envisions\reports\5021.rpt LODI, CA 95242 Care of LODI HOME DAIRY Location Code 02 -LODI BOS District 004 - VOGEL, KEN APN EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone 209-368-94--aB Night Phone 209-36&--9473$ ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0003006 Mail Invoices to Facility Account Name LODI HOME DAIRY Account Balance as of 12/1/2008: $0.00 Program/Element and Description 2011 - GRADE A DAIRY Make changes/corrections in RED ink or pencil. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID 002447 New Owner ID : A lig S LIA 7 ON fiviP Alt Phone Fax EMail : 3 Record ID Employee ID and Name New Account ID: Mail Invoices to: Owner / Status PR0200098 EE0004589 - KADEANNE LINHARES Inactive Facility / Account (Circle One) (Circle One) Transfer to Active/Inactve New Owner? Delete 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 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: Date Program Records to be TRANSFERED: ' $20.00 = Amount Paid Date Water System to be TRANSFERED: ' $372.00 = Amount Paid Date Payment Type _ heck Number Receiv RENS: ' Date Zi I / Account out: Date O / /"P COMMENTS: \\phs-ehsql-nt\apps\envisions\reports\5021.rpt