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05/16/2007 11: 50 209336 INJECTION_MOLISCO PAGE 02/02 <br /> Daterun 5116/2007 9:31:23AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT R.,nd 21 <br /> Run by 4006 Paget <br /> Facility IrtFvrmativn as of 5/16/2007 <br /> R...rd r io*Wh CWmk- Facday IO FA0009802 <br /> Make chengeslcarrecdione in RED Ink or penc' <br /> INFORMATION CHANGE(date) �/T <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Omer 10 OW0007802 Case Number. H05461 New Owner ID : <br /> Owner Name 4AARK4aFjy.A4 7`L/ 4 N e-- <br /> Ovmer DBA A4gL4)GRpET-ER:1—. K/E�z�N' /f a f z r-,v �E 7171T- <br /> Omer <br /> Omter Address 4�M c�^� t- II t p�eS <br /> Home Phone Not� /G.nn C/io .c d11? <br /> Work/Business Phone 209 3337406 <br /> Mailing Address 922 INDUSTRIALWAY <br /> LODI, CA 95240 <br /> Cam of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009802 <br /> Facility Name <br /> Location 922INDUSTRIAL AY ,50J' '2 G <br /> LODI, CA 95240 <br /> Phone 209-333-7406 DlS A-DD ,r°. L� �p nftG7ctr�ss <br /> Mailing Address 922 INDUSTRIAL WAY <br /> LODI, CA 95240 <br /> Care of <br /> Location Code 02-LODI APN:4915011 <br /> Bos❑ielrict 004-VOGEL, KEN SIC Code:9g00 <br /> ACCOUNTS RECEIVABLE FILI~INFORMATION <br /> AccountlD AR0016802 New AccountlD: <br /> Mail Invoices to¢jyylggF,_ Mail Invoices to: Owner / adlity Account <br /> Account Name M••,a„,Dam I <br /> Account Balance as of 6/1612007: $0.00 <br /> Tnunzler to 1 0One) <br /> // ActivOnatdve <br /> PmgreMEhm.M and D...1pbo. R.M In Enpbyee In end Neap at... NewfT.11W7 OeMre <br /> 2221-N3EB-BIL-f3N6Y-e5 TONS/YR PRO522198 EE0000753-WILLIE NG Active M N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO512090 EEOD00000-HAZ MAT SJC DES Inactive Y N A 1 ❑ <br /> 2244-PACT TRANSFER RECORD-OE5 PR0520190 EE0000000-HAZ MAT SJC DES Inactive Y N A I ❑ <br /> 2389-UNIFIED PROGRAM FAC STATE SURCHARPRO509802 EEOOOOOO13-HAZ MAT SJC OES Inactive Y N A 1 O <br /> W1­QNG erA 00MPIJANCE ACKNOWLEDGEMENT: I,the undersigned avmer,OenOnr w agars ar same,hakmvdedga that all ate,andfor prcje t specnc,PHSIEHD hou*0%nies awoNated vat Inie <br /> StcatsY endoor For Fay wa be heed re U.pint McMiaed ea Mm OWNER on Nk rarm. I ebo eppry thal W gMratbre WII be peKonmW m acoer qrp.aeh ell applNefNa OMlneee Cndea andlvr SGndarda and <br /> `p.Vederal wee. ��/' <br /> APPLICANT'S SIGNATURE✓��i1.n . 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: Dated 1 Account out pate / ! <br /> CIDWENT6: <br /> I1phs-ehsgl-ntlappslenvisians\feporta15021.rpt " <br />