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Date run 1/19/2007 9:06:30Ak SAN JOIN COUNTY ENVIRONMENTAL HEAL Pagel <br /> DEPARTMENT Report#5021 <br /> Run by <br /> Facility 1lformation as of 1/19/20 <br /> Record Selection Criteria: Facility ID FA0007882 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CH te) <br /> OWNER FILE INFORMATION <br /> Owner ID OW 005690 New Owner <br /> Owner Name <br /> Owner DBA <br /> Owner Address a� x Ar 1t f 2�dYLrr�t� <br /> g3- Lb <br /> Home Phone <br /> Work/Business Phone <br /> Mailing Address <br /> 06223077' <br /> Care of �� <br /> FACILITY FILE INFORMATION <br /> Facility I FA00078 <br /> Facility Name ARCO#760 <br /> Location 225 S CHEROKEE LN <br /> LODI, CA 95240 <br /> Phone 209-368-7863 <br /> Mailing Address pg BOX 65 19 <br /> MS Sah K cvw.n/\ UCj Lf <br /> Care of.pAtr[-SUP= <br /> Location Code 02 - LODI APN 04314058 <br /> BOB District 004-SEIGLOCK, JACK SIC Code: <br /> ACCOUNTS RECEIVABLE FI MATT N <br /> Account I AR0014495 NewAccount ID: : <br /> Mail Invoices to Mail Invoices to: Owner / Facility / Account <br /> Account Name ARCO#760 Ji-r. : 5(5-2 (Circle one) <br /> Account Balance as of 1/19/2007: $0.00 ry-Vt f t 3C)1 1 K.t <br /> &�� JA CA 9-5Ir?C� (Circle One) <br /> Transfer to Active/Inactye <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2olS7 PR0508009 EE0000942-MARGARET LAGORIO Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or 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 identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes andlor Standards and <br /> Slate and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date <br /> Water System to be T FERED: '$372.00= Amount Paid - / l'?/ <br /> Payment Type Check Number —7D ?�f Received by Zoe_ <br /> REHS: '_'Yl. Date Account out: Date <br /> COMMENTS: <br /> v: l5 �o3q <br /> \\phs-ehsq I-nt\apps\envisions\reports\5021.rpt <br />