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Date run 12/3/2014 11:29:16AI SAN JC ')UIN COUNTY ENVIRONMENTAL HEA '-1 DEPARTMENT <br /> Run by Report#5021 <br /> �.. Facility Information as of 12!3/2014 page' <br /> Record selection Criteria- Facility ID FAD016998 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 SSN!Fed Tax ID <br /> Owner ID 0W0013839 New Owner ID <br /> Owner Name COBLE VINEYARD <br /> Owner DBA COBLE VINEYARD <br /> Owner Address 5479 KILE RID <br /> LODI, CA 95242 <br /> Home Phone 209-712-1817 <br /> Work/Business Phone 209-794-0913 <br /> Mailing Address 5479 KILE RD <br /> LODI, CA 95242 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID!CERS ID FA0016998 10185735 <br /> Facility Name COBLE VINEYARD <br /> Location 5479 KILE RD <br /> LODI, CA 95242 <br /> Phone 209-794-0913 x <br /> Mailing Address 5479 KILE RD <br /> LODI, CA 95242 <br /> Care of MARVIN COBLE <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 00128007 EMail <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0029880 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to Owner / Facility / Account <br /> Account Name COBLE VINEYARD (Circle One) <br /> Account Balance as of 12!3/2014: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PRO525183 EE0008709-JAMIE DE LA ROSA Active Y N A '1 D <br /> 2221 -USED OIL ONLY-<5 TONSIYR PR0538745 EE0009488-JEFFREY WONG Active Y N A `T� D <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0529130 FE0000753-WILLY NG Inactivs Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532081 Inactivir Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHS/EHD hourly charges associated with this facility <br /> 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 Ordinance Codes ancvor Standards and State andler <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 / <br /> Program Records to be TRANSFERED: $25.00 n Amount Paid Date 1 ! <br /> Water System to be TRANSFERED: Amount Paid {late ! ! <br /> Paymente Check Number Recel <br /> REHS: LLAO�n= Date 1 1 LJ Account out: Date !y�! 1 J <br /> COMMENTS: <br /> chin ccs �s f <br />