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Date run 9/12/2007 4:49:58PA SAN JON COUNTY ENVIRONMENTAL HEA EPARTMENT <br /> Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9/12/200 <br /> Record Selection Criteria: Facility ID FA0017827 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner I OW0014638 New OwnerlD <br /> Owner Name MOORE, JAMES G <br /> Owner DBA NEW WEST STATIONS INC <br /> Owner Address 1831 16TH ST <br /> SACRAMENTO, CA 95814 <br /> Home Phone 916-443-0890 <br /> Work/Business Phone Not Specified <br /> Mailing Address 1831 16TH ST <br /> SACRAMENTO, CA 95814 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017827 <br /> Facility Name FLAG CITY SHELL#1003 <br /> Location 6437 W BANNER ST <br /> LODI, CA 95242 <br /> Phone 209-333-1330 <br /> Mailing Address 1831 16TH ST <br /> SACRAMENTO, CA 95242 <br /> Care of NEW WEST STATIONS INC <br /> Location Code 99- UNINCORPORATED AREA APN 05532019 <br /> BOS District 004 -VOGEL, KEN SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0031165 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name FLAG CITY SHELL#1003 / (Circle One) <br /> Account Balance as of 9/12/2007: $p 96' X �- (Circle One) <br /> `j Transfer to Active/Inactve <br /> Program/Element and Description cord ID Employee ID and Name Status New Omen Delete <br /> 2957-UST FILE-RWOCB PR052634 j E0000684-MICHAEL INFURNA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the unde er,operator r agent of same,acknowledge that all site,and/or project spec,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party identMed as the OWNER on this form. I also ce ify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: ,V t'� �' Date / / <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Y3-7 +--Date` � 13 / r0 7 <br /> Payment Type ✓ Check Number O Received by -9 <br /> RENS: Date / Account out: Date / / <br /> COMMENTS: <br /> \\ <br /> \\phs-ehsql-nt\apps\envisions\reports\5021.rpt <br />