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Date run 2/1/2013 11:23:12AM SAN JOL UIN COUNTY ENVIRONMENTAL HEAD DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 2/1/2013 <br /> Record Selection Criteria: Facility ID FA0009921 <br /> Make changestcorrections 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 1D <br /> Owner Name COTTA, JOHN &JAMES <br /> Owner DBA JOHN A COTTA VINEYARDS <br /> Owner Address 5573 W WOODBRIDGE RD <br /> LODI, CA 95242 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 5573 W WOODBRIDGE RD <br /> LODI, CA 95242 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009921 <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 �',fir`•` <br /> LODI, CA 95242-i,\\\f\ <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 01117050 Entail: <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 ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name COTTA, JOHN &JAMES (Circle One) <br /> Account Balance as of 2/1/2013: $138.00 <br /> (Circle One) <br /> Transferto ActiveJlnaclve <br /> 2!!3 Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> QW-HMBP-Common Materials PRO519962 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 1958-HM-Farm Operations PRO524833 EE0000000-HAZ MAT SJC IDES Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO512209 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2226-CaIARP PROGRAM PR0514699 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0509921 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0529625 EE0000753-WILLY NG Active,Exempt Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPRO531574 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,anNor project specific.PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the parry identified as the OWNER on this form I also certify that all operations will be performed in accordance with alt applicable Ordinance Codes andor Standards and Stale anchor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date / I <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / I <br /> Water System to be TRANSFERED: Amount Paid Date / / <br /> Payment Type Check Number Recei <br /> REHS: A- I v VL Dated t Iiount out: Date _1 / 0 <br /> COMMENTS: <br />