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Date run 8/12/2008 3:19:27PN SAN J( JIN COUNTY ENVIRONMENTAL HEQ DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/12/2008 <br /> Record Selection Criteria: Facility ID FA0017792 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0014607 New Owner ID <br /> Owner Name FRANZIA, BRIAN <br /> Owner DBA WEST COAST GRAPE FARMING INC <br /> Owner Address 800 E KEYES RD <br /> CERES, CA 95307 <br /> Home Phone 209-993-9201 <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 488 <br /> CERES, CA 95307 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017792 <br /> Facility Name WEST COAST GRAPE FARMERS <br /> Location 1020 W FOREST LAKE RD <br /> ACAMPO, CA 95220 <br /> Phone 209-538-1794 <br /> Mailing Address PO BOX 488 <br /> CERES, CA 95307 <br /> Care of BRIAN FRANZIA <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 00314001 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name BRIAN FRANZIA <br /> Title <br /> Day Phone 209-538-1794 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0031062 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name WEST COAST GRAPE FARMERS (Circle One) <br /> Account Balance as of 8/12/2008: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 832 AST FAC 10 K-</=100 K GAL CUMULATIVEPRO526952 EE0001422-ARIS CACAPIT Active Y N A I D <br /> -WASTE TIRE SITE-EXEMPT PR0526280 EE0000060-JENNIFER FRASE Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to a party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> 1&1,41 <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: *$372.00= Amount Paid Date / ! <br /> Payment Type Check Number Receive <br /> REHS: <br /> Date / / Account out: Date /J_/ <br /> COMMENTS: <br /> \\phs-ehsgl-nt\a pps\envision s\reports\5021.rpt <br />