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Dat^a ry(L_— 10/18/2004 12:12:22F SAN JOAQUIN COUNTY ENVIRONMENTAL HEAT TH DEPARTM, <br /> Run by . <br /> Facility Information as of 10/1804 <br /> Record Selection Criteria: Facility ID FA0012688 <br /> Make changes/corrections in RED ink or pe, <br /> INFORMATION CHANGE(date) <br /> 'tri=�i"��_ OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0009878 �'__�• New Owner ID <br /> Owner Name WILD ROSE VINEYARDS <br /> Owner DBA WILD ROSE VINEYARDS <br /> Owner Address 1294 COLETTE ST <br /> LODI, CA 95242 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 1294 COLETTE ST <br /> LODI, CA 95242 <br /> Care of ��,{{{��� ��� <br /> FACILITY FILE INFORMATION ----- 9 �a� (r�r y /�-r S 1 S (AC',�.Q� (.1�1�1�+ <br /> Facility ID FA0012688 / <br /> Facility Name WILD ROSE VINEYARS �I I/ <br /> Location �__ _�T INS 7 <br /> L-(DD�4 V"v4,>r- 1 R 5 3 <br /> Phone <br /> Mailing Address 1294 COLETTE ST <br /> LODI, CA 95242 <br /> Care of <br /> Location Code 02 -LODI APN: <br /> BOS District 004 -SEIGLOCK, JACK SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0021092 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name GEOMATRIX CONSULTANTS, INC (circle one) <br /> Account Balance as of 10/18/2004: $0.00 <br /> (Circle one) <br /> Transfer to Active/Inacive <br /> r ent and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2 0- QCB CLEAN UP SITE(SLIC) PRO516580 EE0006219-LORI DUNCAN Active Y N A I D <br /> LUNG 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 /> ility or activity will be billed to the parry 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 /> APPLICANTS 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 /> e Received b <br /> F, Payment Type eck Number 'G y <br /> EJ REHS: ���� Date 0 /�/ Account out: Date A) <br /> I OMMENTS: <br /> L <br /> ic <br /> �_ \\phs-ehsgl-nt\apps\envisions\reports\5021.rpt <br />