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Date run 7/26/2004 10:51:14AI SAN JUIN COUNTY ENVIRONMENTAL HEH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/26/2 <br /> Record Selection Criteria: Facility ID FA0003424 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0002548 Case Number: 002448 New Owner ID <br /> Owner Name LUIZ, EVERETT& SONS DAIRY <br /> Owner DBA LUIZ, EVERETT& SONS DAIRY <br /> Owner Address 18721 N RAY RD <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-369-9290 <br /> Mailing Address 18721 N RAY RD <br /> LODI, CA 95240 <br /> Care of LUIZ, EVERETT&SONS DAIRY <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0003424 <br /> Facility Name LUIZ, EVERETT& SONS DAIRY <br /> Location 18035 N JACOB BROCK RD <br /> LODI, CA 95240 <br /> Phone 209-369-9290 <br /> Mailing Address 18721 N RAY RD <br /> LODI, CA 95240 <br /> Care of LUIZ, EVERETT& SONS DAIRY <br /> Location Code 99 - UNINCORPORATED AREA APN:02511007 <br /> BOS District 004-SEIGLOCK, JACK SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003001 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name LUIZ, EVERETT& SONS DAIRY (Circle One) <br /> Account Balance as of 7/26/2004: $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 /> 2011 -GRADE A DAIRY PR0200101 EE0000018-ROBIN TRINDADE 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 specific,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 and/or Standards and <br /> State 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 TRANSFERED: *$155.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\Ph s-eh sq I-n t\apps\Envisions\Reports\5021.rpt <br />