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Date run : 2/14/01 9:12:23AM %1 JOAQUIN COUNTY PUBLIC HEALTH SERVICES Report #: 0002 <br /> Run by VHAYES <br /> ' Facility Information as of 2/14/01 Page ii: 1 <br /> Record Selection Criteria: Facility ID FA0009021 <br /> RecordlD <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE (date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE (date) <br /> Owner to: OW0007021 Case Number: H00290 New Owner ID <br /> Owner Name; FOREST WILLIAMS <br /> Owner DBA' <br /> Owner Address. <br /> Home Phone: 415-771-2886 <br /> Work/Bussness Phone: 209-368-2424 <br /> Mailing Address: 110 S CHEROKEE LN <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility to: FA0009021 <br /> Facility Name: MENDOCINO ICE CREAM CO <br /> Location: 110 S CHEROKEE LN <br /> LODI, CA 95240 20 <br /> Phone: 209-368-2424 <br /> Mailing Address: 110 S CHEROKEE LN <br /> LODI, CA 95240- <br /> Care of: LARRY HASKIN <br /> Location code: 02-LODI APN; 043-230-11 <br /> BOB District: 004 -SEIGLOCK, JACK SIC Code; <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0016021 New Account ID:: <br /> Mail Invoices to: Account Mail Invoices to: Owner/ Facility/Account <br /> Account Name: MENDOCINO ICE CREAM CO (Circle One) <br /> Account Balance as of 2114/01. <br /> (Circle One <br /> UST(s) Transfer to Active/Inacty <br /> Program/Element and Description Record ID Employee ID and Name Status Linked New Owner? De <br /> 2226-CaIARP PROGRAM PRO614517 EE0000000-SJC DES Active Y N ul 2399-UNIFIED PROGRAM FAC STATE SERVICE F PRO509021 EE0000000-SJC OES Active Y N2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PRO511309 EE0000000-SJC OES Active Y N 2220-SM HW GEN<5 TONSNR PRO513587 EE0003580-STERNI-LE Active Y N <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT.• I,the undersigned owner,operator or agent of-same,acknowledgge that all site,and/orpro/'ed <br /> specific,PHS/EHD hourly charges associated with this faci/iry or activity will be billed to the part identr red as the B/LL/NGPARTYon thisform <br /> also cenify that aB operations win be performed in accordance with all applicable Ordim ee Codes an or Standards and State and/or Federal Laws <br /> APPLIcANT3 31ONATURE: Date / I <br /> Program Records to be TRANSFERED: '$0.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$150.00= Amount Paid Date <br /> Payment Type Check Number Receipt Number Received by <br /> RENS: Date / / Account out: Date <br /> 1.0.0.69.00 <br />