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Date rw 1/21/2010 2:29:57PN SAN JC UIN COUNTY ENVIRONMENTAL HEA 4 DEPARTMENT Report #5021 <br />Run by 5290 Paget <br />Facility Information as of 1/21/2010 <br />Record Selection Criteria: Facility ID FA0019411 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0015911 <br />Owner Name <br />HARRELL, DAVID V <br />Owner DBA <br />Owner Address <br />409COVENAAVE <br />MODESTO, CA 95354 <br />Home Phone <br />209-605-9779 <br />Work/Business Phone <br />209-368-1400 <br />Mailing Address <br />409 COVENA AVE <br />MODESTO, CA 95354 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0019411 <br />Facility Name <br />LODI MOTOR SPORTS <br />Location <br />847 N CLUFF AVE STE C <br />LODI, CA 95240 <br />Phone <br />209-368-1400 <br />Mailing Address <br />847 N CLUFF AVEA STE C <br />LODI, CA 95240 <br />Care of <br />HARRELL, DAVID V <br />Location Code <br />BOS District <br />APN <br />04935014 <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 <br />Mail Invoices to Facility <br />Account Name LODI MOTOR SPORTS <br />Account Balance as of 1/21/2010: $0.00 <br />Program/Element and Description Record ID <br />2220 - SM HW GEN <5 TONS/YR PRO529077 <br />2244 -PACT TRANSFER RECORD -OES PRO529914 <br />Make changes/corrections in RED Ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN <br />/ Fed Tax ID <br />New Owner ID : <br />rjA 1 AfJ SAf 1z. <br />YV1v�E5Ty P1f� 4��'i / <br />„r1,, AN�iAS t/it= <br />Alt Phone <br />Fax <br />EMail : <br />New Account ID: <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/InacNe <br />Employee ID and Name Status New Owner' Delete <br />EE0001422 - ARIS CACAPIT Active Y N A I D <br />Active Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned comer, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated wnh 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 Ordinace Codes and/or Standards and <br />State and/or Federal Lam, <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />REHS: <br />COMMENTS: <br />\\eh-env\envision\reports\5021.rpt <br />Date <br />' $20.00 = Amount Paid Date <br />' $372.00 = Amount Paid Date <br />Received It <br />_ Date / I Account out: _ Date / eZ <br />L ptt X675 41- <br />