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Date run 3/18/2004 9:29:52AN SAN JOA` 7 JIN COUNTY ENVIRONMENTAL HEAI — DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/18/20t, <br /> Record Selection Criteria: Facility ID FA0000454 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0000373 New Owner ID <br /> Owner Name CANTON, ANTHONY <br /> Owner DBA <br /> Owner Address 1029 S CHURCH �'? L 1�£� C`S <br /> LODI, CA 952400419 <br /> Home Phone 209-334-9590 <br /> Work/Business Phone Not Specified <br /> Mailing Address 1029 S CHURCH 5F}f G- <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 1029 S CHURCH 01- Y t1r, <br /> LODI, CA 95240 <br /> Care of CANTON, ANTHONY <br /> Location Code 99 - UNINCORPORATED AREA APN:06104007 <br /> BOS District 004 - SEIGLOCK, JACK SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000453 NewAccount ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name CANTON, ANTHONY (Circle One) <br /> Account Balance as of 3/18/2004: $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 /> 2755-EMPLOYEE HOUSING PR0270120 EE0001522-JAMES VAN BUREN 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: nom_ Date <br /> COMMENTS: <br /> f )l Il jv ' 819RAED VJINEI� (9K 4 <br /> V 4 0m),- TF-R m IT �4 —&IVN G rN . <br /> \\Phs-ehsql-nt\apps\Envisions\Reports\5021.rpt <br />