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Date 013 4:31:10PM SAN JOIN COUNTY ENVIRONMENTAL HEA*DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 5/9/2013 <br /> Record Selection Criteria: Facility ID FA0007750 <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 OW0006411 New Owner ID <br /> Owner Name LA- <br /> Owner DBA pe051A <br /> Owner Address Lt c -7 0 <br /> L�nl �^ 052103 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-365-7500 'j/'3 D — / l <br /> Mailing Address 300 S BECKMAN <br /> LODI, CA 952403103 <br /> Care of BEASLEY, LAWRENCE <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0007750 <br /> Facility Name Apke ;`p-LA&T-feS— <br /> Location 300 S BECKMAN RD <br /> LODI, CA 952403103 <br /> Phone Zd- S <br /> Mailing Address <br /> LnnlGA 95240—_ 57 A- <br /> Care of <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN """�-425� 049 3 111DZ) � EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name 5 LJv V1 0W7P'(., tzs'ur"a(,�' <br /> Title I NTLI AG, , <br /> Day Phone Q O / &L-Mr-1V 320 <br /> Night Phone 2.08-985-_-75M —uIUC O <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0013765 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility ! ccount <br /> Account Name SAINT-GOBAIN CORPORATION (Circle One) <br /> Account Balance as of 5/9/2013: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PRO507767C€A96��d�9)) f F ALE Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent„��LR2i ,�2ck owl9dge at all site,and/or 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 and/or Standards and State and/or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: `' ` �� ` �� ��� Date 6-/ 2/ /-3 <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 by _ <br /> REHS: Date / / Account out: ate S /�7 <br /> COMMENTS: <br />