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Date run 5/16/2002 10:49:52AI SAN JC TIN COUNTY ENVIRONMENTAL HEAL ')EPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 5/16/2002 <br /> Record Selection Criteria: Facility ID FA0013830 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0010927 New Owner ID <br /> Owner Name KIKUCHI, DANIEL/KITASOE, LORRA <br /> Owner DBA <br /> Owner Address 2291 W MARCH LN A101 <br /> STOCKTON, CA 95207 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 1301 W LOCKEFORD ST <br /> LODI, CA 95242 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013830 `�— <br /> Facility Name KIKUCHI/KITASOE PROPERTY <br /> Location 1301 W LOCKEFORD ST <br /> LODI, CA 95242 <br /> Phone <br /> Mailing Address 2291 W MARCH LN STE A101 <br /> STOCKTON, CA 95207 <br /> Care of <br /> Location Code 02- LODI APN: <br /> BOS District SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0023277 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility ! Account <br /> Account Name SHARO ENSflN CACONE (Circle One) <br /> Account Balance as of 5/16/2002: 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 PR0518316 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 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 Typ Check Number Received by <br /> RENS: Date / f to / 6 Z Account out: Date <br /> COMMENTS: <br /> \\Phs-ehsql-nt\apps\Envisions\Reports\5021.rpt <br />