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Date run 6/29/2009 4:21:11PK SAN JOt'IUIN COUNTY ENVIRONMENTAL HEAI —'i DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 6/29/20,-- <br /> Record Selection Criteria: Facility ID FA0000454 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0000373 New Owner ID <br /> Owner Name CANTON, ANTHONY <br /> Owner DBA <br /> Owner Address 1729 LE BEC CT -1291 IYliclll� L <br /> LODI, CA 952400419 CA 9520 <br /> Home Phone 209-334-9590 <br /> Work/Business Phone Not Specified <br /> Mailing Address 1729 LE BEC CT /�3 /�lcdtl•*-,OL �s� <br /> LODI, CA 952400419 <br /> Care of CANTON, ANTHONY <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0000454 <br /> Facility Name CANTON LABOR CAMP 39-120 <br /> Location 13631 N HURD RD <br /> LODI, CA 95240 <br /> Phone 209-334-9590 <br /> Mailing Address 1729 LE BEC CT /2�/ Ij'lcdva•CG FZd <br /> LODI, CA 952400419 Com' 9S —4S�S <br /> Care of CANTON, ANTHONY <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 06104007 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name CANTON,ANTHONY <br /> Title <br /> Day Phone 209-334-9590 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000453 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name CANTON, ANTHONY (Circle One) <br /> Account Balance as of 6/29/2009: $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 /> 2765-EMPLOYEE HOUSING-PERMANENT>180 D/PR0270120 EE0008987-SCOTT SANGALANG 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: '$372.00= Amount Paid Date / / <br /> Payment T e Check Number Received b <br /> REHS: Date ACV 7, D q Account out: Date 1 /— 'Z /()9 <br /> COMMEN 7 �r <br /> \\eh-env\envision\reports\5021.rpt <br />