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Date run 10/18/2007 3:46:29P SAN JOf 9�IN COUNTY ENVIRONMENTAL HEAL-o"I DEPARTMENT Report#5021 <br /> Run by 5290 ✓•r Pagel <br /> Facility Information as of 10/18/20t7-r- <br /> Record Selection Criteria: Facility ID FA0013598 <br /> Make changes/corrections In RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0010715 New Owner ID <br /> Owner Name WESTER, BERNIE --t— 1—„ P F <br /> Owner DBA <br /> Owner Address 1102 BLACK DIAMOND WAY <br /> LODI, CA 95240 <br /> Home Phone 209-334-4331 / S� <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 2693 446DyC <br /> LODI, CA 95241 <br /> Care of WESTER, BERNIE \ <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013598 <br /> Facility Name VIKING AUTOMATIC SPRI KL COMPANI <br /> Location 1102 BLACK DIAMOND WAY <br /> LODI, CA 95240 <br /> Phone 209-334-4331 <br /> Mailing Address PO BOX 2693 <br /> LODI, CA 95241 <br /> Care of WESTER, BERNIE 11 'u L-ha a <br /> Location Code 02-LODI APN:04918020 <br /> BOS District 004 -VOGEL, KEN SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0022732 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner I Facility / Account <br /> Account Name VIKI AUTOMATIC SPRINKLER COMPANY, <br /> ( �y"� (Circle One) <br /> Account Balance as of 10118 V' (Circle one) <br /> Transfer to ACircle actrve <br /> One) <br /> New Diener? Delete <br /> ProgranvElement and Descnption Record ID Employee ID and Name Status <br /> 2220-SM HW GEN<5 TONS/YR PR0517809 EE0009155-TOUA YANG Active Y N A I D <br /> 2.224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO517811 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0520972 EEOOOOOOO-HAZ MAT SJC DES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARlPRO517810 EE0000000-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,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the parry Identified as the OWNER on this form. I also certify that all operations will be performed in accordance With all applicable Ordinate Codes and/or Standards and <br /> State andlor Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date / / <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date—L-0 /—YL/_AL� <br /> COMMENTS: 9L"/] <br /> �---- <br /> \lphsehsgl-nt\apps\envisions\reports\5021.rpt <br />