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Date run g/�+7l2009 10:52:28AI SAN JOAN COUNTY ENVIRONMENTAL HEAL i ' EPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8127120 <br /> Record Selection Criteria: Facility ID FA0018998 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0007432 New Owner ID <br /> Owner Name CITY OF LODI <br /> Owner DBA <br /> Owner Address 221 W PINE ST <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-333-6706 <br /> Mailing Address PO BOX 3006 <br /> LODI, CA 952411910 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0018998 <br /> Facility Name NCPA LODI ENERGY CENTER <br /> Location 12751 N THORNTON RD <br /> LODI, CA 95242 <br /> Phone <br /> Mailing Address 221 W PINE ST <br /> LODI, CA 95240 <br /> Care of CITY OF LODI <br /> Location Code 02 - LODI Alt Phone <br /> SOS District 004 -VOGEL, KEN Fax <br /> Al 05513016 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0033784 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name -NORTHERN-CAP (Circle one) <br /> Account Balance as of 8127/2009: $0.00 3{ <br /> (Circle One) <br /> Transfer to Active/Inacive <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PR0528038 EE0003611 -FRANK GIRARDI Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT; I,the undersigned owner,operator or agent Df same,acknowledge that all site,andlor project specific,PHSIEHD 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 and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Q' Date 1 I <br /> Program Records to be TRANSFERED: $20.00= Amount Paid Date <br /> Water System to be TRANS RED: '$372.00 }= Amount Paid Date 1 ! <br /> Payment Type / Check Number Received by — ' <br /> RENS: Date / 1 Account out: Date 1�1 <br /> COMMENTS: PAYMENT <br /> `93q RECEIVED <br /> AUG 2 7 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> lkeh-envlenvisionlreports15021.rpt HEALTH DEPARTMENT <br />