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Date run 4/20/2005 11:40:27AI SAN� ,/ <br /> Run by UIN COUNTY ENVIRONMENTAL HE%H DEPARTMENT Report#5021 <br /> Facility Information as of 4/20/ Pagel <br /> Record Selection Criteria: Facility ID FA0000541 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) - <br /> Owner ID OW0000443 New Owner ID <br /> Owner Name PACIFIC COAST PRODUCERS <br /> Owner DBA PACIFIC COAST PRODUCERS CLUFF <br /> Owner Address 631 N CLUFF <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-367-8800 <br /> Mailing Address PO BOX 880 <br /> LODI, CA 95241 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0000541 <br /> Facility Name PACIFIC COAST PRODUCERS* <br /> Location 835 S STOCKTON ST <br /> LODI, CA 95240 <br /> Phone 209-334-4411 <br /> Mailing Address PO BOX 270 <br /> STOCKTON, CA 952010270 <br /> Care of <br /> Location Code 02 - LODI APN:N/A <br /> BOS District 004-SEIGLOCK, JACK SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000540 <br /> New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name PACIFIC COAST PRODUCERS" <br /> Account Balance as of 4/20/2005: $0.00 Circe One) <br /> Pro (Circle One) <br /> Program/Element and Description Transfer to Active/Inactve <br /> Record ID Employee ID and Name Status New Owner? Delete <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO511880 EE0000000-HAZ MAT SJC DES Inactive <br /> 2244-PACT TRANSFER RECORD-DES PRO519753 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2248-RCRA GEN 25<50 TONS PR0220087 EE0008389-DENNIS CATANYAG Inactive Y N A I D <br /> 2301 -UST STATE SURCHARGE FEE PRO507682 EE0003580-MICHELLE LE Inactive Y N A I D <br /> 2361 -UST FACILITYPR0231887 EE0008389-DENNIS CATANYAG Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARIPRO507252 EE0003580-MICHELLE LE Inactive Y N A D <br /> Y N A I p <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 party identified as the OWNER on this form. I also cergfy that all operations will be performed in accordance with all applicable Ordinace Codes and/or standards and <br /> State and/or Federal Laws. <br /> APPLICANTS SIGNATURE: <br /> Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: "$155.00= Amount Paid Date <br /> Payment Type Check NumberREHSReceived by <br /> COMMENTS <br /> �M(cr Date oy/ / '05 Account out: _Ild_ Date / O /0 <br /> COMMENTS: <br /> \\phs-ehsgl-nt\apps\envisions\reports\5021.rpt <br />