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Date run 5/25/2010 3:04:36PR SAN JO.*N COUNTY ENVIRONMENTAL HEAI•DEPARTMENT Report#5o21 <br /> Run by Page 1 <br /> Facility Information as of 5/25/201 U <br /> Record Selection Criteria: Facility ID FA0020331 <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 OW0002544 Case Number: 002442 New Owner ID <br /> Owner Name WOODS, ERWIN F ETAL <br /> Owner DBA <br /> Owner Address 14250 N DE VRIES RD <br /> LODI, CA 95242 <br /> Home Phone 209-368-9846 <br /> Work/Business Phone 209-369-2514 <br /> Mailing Address 14250 N DE VRIES RD <br /> LODI, CA 95242 <br /> Care of WOODS, ERWIN & MARIE ANNA <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0020331 <br /> Facility Name WOODS DAIRY <br /> Location 14250 N DE VRIES RD <br /> LODI, CA 95242 <br /> Phone 209-601-5240 <br /> Mailing Address 14250 N DE VRIES RD <br /> LODI, CA 95242 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 05524026 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0036312 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name WOODS DAIRY (Circle One) <br /> Account Balance as of 5/25/2010: $-345.00 <br /> (Circle One) <br /> Transfer to ActivenlnacNe <br /> Program/Element and DescriptionRecord ID Employee ID and Name Status New Omer? Delete <br /> 2965-WATER QUALITY SITE PROJECT PR0535173 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,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 Ordinate Codes anNor Standards and <br /> State andror Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: $20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date / / <br /> Payment Type Check Number Received by <br /> RENS: Date / / Account out: Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />