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Date run 12/31/2009 10:33:08/ SAN J@9 'UIN COUNTY ENVIRONMENTAL HEAI " '6 DEPARTMENT Report#5021 <br /> Ranby <br /> '�� ' Facility Information as of 12131/20179` Paget <br /> Record Selection Criers: Facility ID FA0013598 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) I - 10 <br /> OWNER FILE INFORMATION SSN/Fed Tax 10 <br /> Owner ID OW0010715 New Owner ID : <br /> Owner Name TATE, MICHAEL M{11Z4 CYARPENT59- <br /> Owner DBA VIKING AUTOMATIC SPRINKLER COM (A; <br /> Owner Address 3245 NW FRONT AVE \ CE RICE <br /> PORTLAND, OR 97210 BiLLIN6S1 MomrANA S9161 <br /> Home Phone 503-227-1171 40(e - 252-5169 <br /> Work/Business Phone Not Specified O(o - Z-*5 S76b <br /> Mailing Address 3245 NW FRONT AVE <br /> PORTLAND, OR 97210 gE $ "00-C <br /> Care of TATE, MICHAEL <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013598 <br /> Facility Name VIKING AUTOMATIC SPRINKLER COMPANI Be. SKY FWX- <br /> Location 1102 BLACK DIAMOND WAYl lb2 BLgCK �1RMOW <br /> LJAy <br /> LODI, CA 95240 W01f CPrr AS240 <br /> Phone 209-334-4331 2pq• 3(05-04go <br /> Mailing Address 3245 NW FRONT AVE $531 C5PJ9I< ROaD <br /> PORTLAND, OR 97210 91LLIpGC i1lONr#A)A 59101 <br /> Care of TATE, MICHAEL M AjeZj Cj4ppe-III <br /> Location Code 02-LODI Alt Phone <br /> BOS District 004-VOGEL, KEN Fax 40(0 ' 2 5<4 -5933 <br /> APN 04918020 EMail: LKtjiFWjEca3816SkY I=iim <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION IRk0TF-CTION COM <br /> Contact Name BERNIEWESTER L"'-JU N <br /> Title 012A ce, aly p 6-er <br /> Day Phone 209-334-4331 2 09- 3��4 010 <br /> Night Phone 2bA , (��Q(o 2 O <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0022732 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name VIKING AUTOMATIC SPRINKLER COMPANY (Circle One) <br /> Account Balance as of 12/31/2009: $0.00 <br /> (Circle One) <br /> Transfer to Activennachn' <br /> Program Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONSNR PRO517809 EE0001422-ARIS CACAPIT Active 4 NA I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO517811 EE0000000-HAZ MAT SJC DES Inactive N A I D <br /> 2244-PACT TRANSFER RECORD-IDES PR0520972 EE0000000-HAZ MAT SJC DES Active Y N A 1 D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPRO517810 EEOD00000-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,anElor 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 Ordinate Codes amilor Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: \'/�� Date l U l 10 <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date / / <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date / I <br /> Payment Type — Check Number Recall <br /> REHS: Date \ / S / /0 Account out: /41t2 <br /> COMMENTS: <br /> �0.t81tG�nr>t 0�(j/L,�1`mt {"�'� Ya$Id^^� I'N �'C Q1,�.�C' �0✓ IS7W JU� � r, �' ��1 Vl-Lu+' IN 'Ihi Cr.�f/o. <br /> \\eh-env\envision\reports\5021.rpt ((1 �'- <br />