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Dale run 7/8/2013 4:21:32PM SAN JOS' 'IN COUNTY ENVIRONMENTAL HEALIDEPARTMENT Report#5021 <br /> Run by N/ Pagel <br /> Facility Information as of 7/8/2013 <br /> Record Selection Criteria: Facility ID FA0009921 <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 OW0007921 Case Number: H05823 New Owner ID <br /> Owner Name COTTA, JOHN &JAMES <br /> Owner DBA JOHN A COTTA VINEYARDS <br /> Owner Address 2440 W TURNER RD APT 142 <br /> LODI, CA 95252-4109 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 2440 W TURNER RD <br /> LODI, CA 95242-4109 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility 10/CERS to FA0009921 10,183,033 .1/l.6 L4 I L/di'—+j 11 2-Q --� <br /> Facility Name JOHN A COTTA VINEYARDS <br /> Location 5573 W WOODBRIDGE RD <br /> LODI, CA 95242 <br /> Phone 209-334-0445 x0 <br /> Mailing Address 2440 W TURNER RD APT 142 <br /> LODI, CA 95242-4109 <br /> Care of <br /> Location Code 99-UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 01117050 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 AR0016921 New Account to: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name COTTA, JAMES (Circle One, <br /> Account Balance as of 7/8/2013: 14 <br /> (Circle One) <br /> Transfer to AcWeAre he <br /> PrograMElement and Description Record ID Employee ID and Name Slatus New Owner? Delete <br /> 1�-HMBP-Common Materials PR0519962 EE0008709-JAMIE DE LA ROSA Active Y N A ® D <br /> 5,x <br /> 19 -HM-Farm Operations PR0524833 Active Y N A ® D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512209 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2226-CaIARP PROGRAM PR0514699 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0509921 EE0000000-HAZ MAT SJC DES Ir tivE Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PRO529625 EE0000753-WILLY NG Active,l Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0531574 InactivE Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anclor 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 Cortes anchor Standards and State sharer <br /> Faaeral Lewis <br /> APPLICANTS SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date / / <br /> Water System to be TRANSFERED: Amount Paid Date_/_/ <br /> Payment Type1—�Check Number 1 Receiv y <br /> RE/H`S< YI��L/' �l-�C.l.L1 t�IJ/j��S�/O//—�(� r/Date A24 11,� Account out: Date / 13 <br /> 0— <br /> COMMENTS Ic3�al.�:1-4+ 60%aa `. / 1[_ , <br />