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Date run 10/9/2013 4:55:24Pk SAN JUIN COUNTY ENVIRONMENTAL HE Report#5021 <br /> DEPARTMENT Pagel <br /> Run by Facility Information as of 10/9/2013 <br /> Record Selection Criteria: Facility ID FA0013608 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0010723 New Owner ID <br /> owner Name S J COUNTY HISTORICAL MUSEUM <br /> Owner DBA <br /> Owner Address PO BOX 30 <br /> LODI, CA 952410030 <br /> Home Phone 209-953-3460 <br /> Work/Business Phone 209-663-9324 <br /> Mailing Address PO BOX 30 <br /> LODI, CA 952410030 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0013608 10,184,453 <br /> Facility Name SJ COUNTY HISTORICAL MUSEUM <br /> Location 11793 N MICKE GROVE RD <br /> LODI, CA 95240 <br /> Phone 209-953-3460 <br /> Mailing Address PO BOX 30 <br /> LODI, CA 952410030 <br /> Care of <br /> Alt Phone <br /> Location Code 02- LODI <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 05910002 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name STUART, DAVID <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION New Account 10: <br /> Account ID AR0022742 <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> (Circle one) <br /> Account Name SJ COUNTY HISTORICAL MUSEUM <br /> Account Balaocg as of 10/9/2013: $0.00 (Circle One) <br /> I Transrerto AcliveAnactve <br /> /� / Status New Owner? Delete <br /> ProgamVd ement and Description Record ID Employee ID and Name <br /> 21 / MBP-Regular-Primary Location PR0517835 EE0008709-JAMIE DE LA ROSA Active,l Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO517833 EE0001422-ARIS CACAPIT Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0517834 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532189 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent Df same,acknowledge that all site,ancifor project specific,PHS/EHD hourlycharges associated with this facility <br /> or activity will be billed to the party idenl�ed as the OWNER on this fmm. Ialsocenify that all operations will be performed in accordance with all applicable Ordinance Codes andror Standards and Slateandar <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date <br /> Amount Paid Date <br /> Water System to be TRANSFERED: Received y <br /> Payment Type rrCCheck Number <br /> \n 1n Q 11fd � Date_-,Q__/ Account out: Date�= <br /> REHS: �i <br /> COMMENTS: <br /> (�v ( 161 I1 M <br />