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02/02/2006 09:03 4640138 ENVIK'UNMENIAL HEALIH NAGE 01 <br /> Da V.M 1/18/2006 2:59:05M SAN JUIN COUNTY ENVIRONMENTAL HEALTIWIPARTMENT Ration 05021 <br /> Run by Paget <br /> Facility Information as of 1/18/2006 <br /> Rada saims"cmada: radrty Io FA0000483 <br /> Make changeslcr Ilona In RED Ink or pencil. <br /> INFORMATION CHANGE(date) 1P� <br /> O� fA�b OWNERSHIP CHANGE(date) __ ,/Jl" <br /> OWNER FILE INFORMATIOi�0 M� 44k� IFyy p �,r <br /> Owner ID QMAXXM=3 ��Z2�l 2`i$ New Owner ID <br /> Owner Name n__75 'S {Ve}R,O �_n <br /> Owner DBA 'pi T LL'S --7 Co <br /> Owner Address } ,�T7CTR' Sia Gyp �4�1 tom,, <br /> ra C-L. <br /> Home Phone N _ fl <br /> Work/Business Phone ^^^�-a48-9 4.2 ei2001- 3b7 - <br /> Mailing Address R &33 E tliC702 R() S&- Irl <br /> fodr C/I` <br /> Care of ..—y,S IOC:lyfl �n f <br /> FACILITY FILE INFORMATION �(}��( S 0 a - 7J e a) L{21`I <br /> Faclllty ID --y <br /> Faclllty Name 'S 76" <br /> Location 633 E VICTOR RD A <br /> LODI, CA 95240 <br /> Phone 209-367-1795 <br /> Mailing Address 166 FRANK WEST CIR S'pc 4 <br /> Care o1 STOCKTON, CA 96206 r-0 RECEIVED <br /> Location Code 02.LODI APN.04321055 <br /> SOS District 004. SEIGLOCK. JACK SIC Coee.9900 FEB —2 20ffi <br /> ACCOUNTS RECEIVABLE FILE INFORMATION bAN JOAQUIN COUNTY <br /> AR0010576/ New Account Ib: : OFFICE OF EMERGENCY SERVICES <br /> Account I <br /> Mail Invoices �� .T13S R—,IT-0 -Lv\C ' Mail Invokes to: Owner acility / count <br /> Account Name V <br /> Account Balance as of 1/18/2006; $0.00 <br /> (ckdk coal <br /> rm,.tnro Acaysimanse <br /> ProgramlElemeN wd Desalotkn Record ID Emp""ID wd Na ,, stetw Now oN"°r' OeMe <br /> 1616-RETAIL MARKET<1000 SO FT W/FOOD PPRo162994 EE0006213-VIDAL PEORAZA Active Y N A I D <br /> . <br /> 2220.SM FM/GEN<5 TONS/YR PR0518577 EE0008493-LORI LUCES Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO513118 EE000D000-WIZ MAT SJC DES Inactive Y N A I O <br /> a 2244-PACT TRANSFER RECORD-DES PR0520512 EE0000000-HAZ MAT SJC DES Acdva Y N A I D <br /> 2301-UST STATE SURCHARGE FEE PR0515535 EE0003580-MICHELLE LE Inactive Y N A I D <br /> a 2361-VST FACILITY - PRO232519 EEOOD8493-LORI LUCES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR�PRD507247 EE0003680-MICHELLE LE Inactive Y N A 1 D <br /> BILLING ane COMPLIANCE ACKNOWLEDGEMENT: M undmigded ormar,operator m agsnl d same.acknaMedge mm an ane,sndler proleel spedald.PNgRND homy asrgos sssacaled Mai IN$ <br /> scary or aeNsy wa as Mkd to me pony IdsMlrnd a OWNER en ml°ronn. I also cartay mat am p Mims r me psemmad In emvffi re vain sa eppaaeble OMnsoo Corn antler Slanaarm ano <br /> Sme aM/or Fedardl Ltws. <br /> APPLICANTS SIGNATURE: Date / 11 06 <br /> Program Re cds to be TRANSFERED: '$20.00= Amount Paid Date /�_I D b <br /> WateiaiaR�E <br /> 372.00= Amount Paid Date_/_/_ <br /> � RecaNed/�bney-� N &ate Account ouL CT Date /_„�! MEN <br /> COMMENTS: <br /> fOD � Qe� w:k Va\�� a��� ob — �"Y3 tion <br /> FEH 01 <br /> 2.1 "1 \Z-- � 1.3 k/06 SAIy Zoos <br /> oirv>yfj� �C rY <br /> \\phs-ehsql-nt\apps\envlslms\repods\SD21.rpt N-.,JCh� ��(� `v, -„ \ �1rSP• S �N7 <br />