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Date run . 6/16/2005 3:18:10PN SAN JOIN COUNTY ENVIRONMENTAL HEAL' DEPARTMENT Report#5021 <br />`Run by Pagel <br />Facility Information as of 6/16/200ti <br />Record Selection Criteria: Facility ID FA0004389 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0003304 <br />Owner Name <br />MAINLAND NURSERY INC <br />Owner DBA <br />MAINLAND NURSERY INC <br />Owner Address <br />50 W TURNER RD <br />Phone <br />LODI, CA 95240 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-334-1680 <br />Mailing Address -50----WTHRN-ER FAD <br />LODt,-CA--95240 <br />Care of MAINLAND NURSERY INC <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0004389 <br />Facility Name <br />MAINLAND NURSERY INC <br />Location <br />50 W TURNER RD <br />LODI, CA 95240 <br />Phone <br />209-334-1680 <br />Mailing Address W ---W TURNER- RD <br />LODI, CA -95240 <br />Care of MAINLAND NURSERY INC <br />Location Code 99 - UNINCORPORATED AREA <br />BOS District 004 - SEIGLOCK, JACK <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0004071 <br />Mail Invoices to Facility <br />Account Name MAINLAND NURSERY INC <br />Account Balance as of 6/16/2005: $0.00 <br />Make changes/corrections in RED ink or pencil. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />New Owner ID <br />APN:02902059 <br />SIC Code: <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Pro m/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />2390 - ABOVEGROUND TANK (SPCC) PR0515644 EE0003580 - MICHELLE LE Active Y N A I D <br />4630 - NTNC WATER SYSTEM WA0461196 EE0000102 - STEVE MINDT Active 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 hourty charges associated with this <br />facility 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 Ordinace Codes and/or Standards and <br />State andlor Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />REHS: <br />COMMENTS: <br />\\phs-ehsql-nt\apps\envisions\reports\5021.rpt <br />* $20.00 = <br />*$155.00=_ <br />Date <br />Date / / <br />Amount Paid Date <br />Amount Paid Date <br />Received by _ <br />Account out: � Date <br />