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Date run 9/7/2010 8:29:31AM SAN JO UIN COUNTY ENVIRONMENTAL HEA- ,;DEPARTMENT Report M21 <br /> Run by �sr �.al Pagel <br /> Facility Information as of 9/7/2010 <br /> Record Selection Criteria: Facility ID FA0019411 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0015911 New Owner ID <br /> Owner Name HARRELL, DAVID V <br /> Owner DBA <br /> Owner Address 531 KANSAS AVE <br /> MODESTO, CA 95351 <br /> Home Phone 209-605-9779 <br /> Work/Business Phone 209-368-1400 <br /> Mailing Address 531 KANSAS AVE <br /> MODESTO, CA 95354 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0019411 <br /> Facility Name LODI MOTOR SPORTS <br /> Location 847 N CLUFF AVE STE C <br /> LODI, CA 95240 <br /> Phone 209-368-1400 <br /> Mailing Address 847 N CLUFF AVEA STE C <br /> LODI, CA 95240 <br /> Care of HARRELL, DAVID V <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 04935014 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name DAVID V HARRELL <br /> Title <br /> Day Phone 209-368-1400 <br /> Night Phone 209-605-9779 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0034518 New Account ID <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name LODI MOTOR SPORTS (Circle One) <br /> Account Balance as of 917/2010: $0.00 <br /> (Circle One) <br /> Pmgram/Element and Description Record ID Employee ID and Name Transfer to AchwtMadw, <br /> Status New Owner' Delete <br /> 2220-SM HW GEN<5 TONS/YR PRO529077 EE0001422-ARIS CACAPIT Active Y N A 7 - D <br /> 2244-PACT TRANSFER RECORD-OES PRO529914 Active Y N A - D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PR0534165 Active 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 Nis <br /> facility or activity will be billed to me party identified as the OWNER on this form. 1 also certify that all operations will be performed in accordance with all applicable Ontinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Receive <br /> REHS: U�i Date Of / / I <br /> �_ Account out: Date <br /> COMMENTS: <br /> \\eh-env\envision\reportsk502l.rpt <br />