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Date run 2/15/2011 10:40:45AI SAN JO,' –UIN COUNTY ENVIRONMENTAL HEAI —I DEPARTMENT Report#5021 <br />Run by , Pagel <br />Facility Information as of 2/15/20 , <br />Record Selection Criteria: Facility ID FA0004389 <br />FACILITY FILE INFORMATION <br />Facility ID <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 />Mailing Address <br />LODI, CA 95240 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-334-1680 <br />Mailing Address <br />PCrg())(-TM0 <br />Care of <br />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 <br />P9-BCW,41l30 <br />W <br />Care of <br />MAINLAND NURSERY INC <br />Location Code <br />99 - UNINCORPORATED P <br />Bos District <br />004 - VOGEL, KEN <br />APN <br />02902059 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <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 2/15/2011: $724.00 <br />Program/Element and Description <br />Record ID Employee ID and Name <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />B a C u a 1 S Y '-- vk5 �" <br />0. S a. <br />Alt Phone <br />Fax <br />EMail : <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Status New Owner? Delete <br />2832 - AST FAC 10 K - </=100 K GAL CUMULATIVEPR0515644 EE0001422 - ARIS CACAPIT Active Y N A I D <br />ERSC - ELECTRONIC REPORTING SURCHARGE PRO532399 Active Y N A I D <br />4630 - NTNC WATER SYSTEM WA0461196 EE0005838 - ADRIENNE ELLSAESSEInactive 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 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 and/or Federal Laws. <br />APPLICANT'S SIGNATURE: 5 -e G \N\0.\� `C' `}- , � c�ate 2— <br />Program <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />REHS: <br />COMMENTS <br />\\eh-env\envision\reports\5021. rpt <br />$25.00 = <br />Date <br />Amount Paid Date <br />_ Amount Paid Date / / <br />Received by <br />Account out: N C's Date <br />