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Date ran 7/30/2004 11:26:43AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/30/ <br /> Record Selection Criteria: Facility ID FA0012448 <br /> Make changeslcorrections in RED ink or pencil. <br /> INFORMATION CHANGE(dale) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0009655 New Owner ID <br /> Owner Name R LAWSON ENTERPRISES <br /> Owner DBA WILD ROSE VINEYARDS <br /> Owner Address 8751 E HWY 12 <br /> VICTOR, CA 95233 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-339-0102 <br /> Mailing Address PO BOX 298 <br /> VICTOR, CA 95253 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012448 <br /> Facility Name WILD ROSE VINEYARDS <br /> Location 8751 E HWY 12 <br /> VICTOR, CA 95253 <br /> Phone 209-339-0102 <br /> Mailing Address PO BOX 298 <br /> VICTOR, CA 95253 <br /> Care of <br /> Location Code 99- UNINCORPORATED AREA APN 05106004 <br /> BOS District 004-SEIGLOCK, JACK SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0020305 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name R LAWSON ENTERPRISES (Circle One) <br /> Account Balance as of 7/30/2004: $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 /> 2214-CalARP FAC STATE SURCHARGE FEE PR0519014 EE0009999-SITE UNASSIGNED Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0516077 EE0009999-SITE UNASSIGNED Active Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PR0520856 EE0000000-HAZ MAT SJC IDES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPR0516078 EE0009999-SITE UNASSIGNED Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowletlge 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 /> Slate 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 /> \\Phs-ehsgl-nt\apps\Envisions\Reports\5021.rpt <br />