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Date run 8/30/2012 9:19:07AK SAN JO*IN COUNTYZNVIRONMENTAL HEAL*EPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/30/2012 <br /> Record Selection Criteria: Facility ID FA0017827 <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 OW0014638 New Owner ID : <br /> Owner Name meeRE—. JAfg1E-$$ Lf'- al-tv L. <br /> Owner DBA <br /> Owner Address 1,8146T+ � <br /> SAGRAPIENTO CA 814 <br /> Home Phone 944-44-@Q..r <br /> Work/Business Phone Not Specified <br /> Mailing Address 186'Y"1b6•TRFST <br /> Care of <br /> FACILITY FILE INFORMATION lil7� <br /> Facility ID FA0017827 <br /> Facility Name FLAG CITY SHELL t3 <br /> Location 6437 W BANNER ST <br /> LODI, CA 95242 <br /> Phone 2gg-355-1r3M <br /> Mailing Address 1 ST- <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 05532019 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION ^ <br /> Contact Name J G-rot@pRE <br /> Title pRErStOrE97 0 aX <br /> Day Phone 209`333-1130 1 y L ,N <br /> Night Phone 9 444j-OW 9 14 2-j�- <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0031165 New Account ID: <br /> Mail Invoices to Account Mail l nvoices to: Owner / Facility / Account <br /> Account Name (Circle One) <br /> Account Balance as of 8130/2012: $0.00 <br /> (Circle One) <br /> Transfer to Active/InacNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2957-UST FILE-RWQCB PR0526345 EE0000684-MICHAEL INFURNA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anNor project specific,PHS/EHD hourly charges associated with this facility <br /> 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 Ordinance Codes ansor Standards and Stale andfor <br /> 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 Received y <br /> RENS: Date /_/ Account out: d Date ?—S- /-:3 0/ {�� <br /> COMMENTS: <br />