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Date run 7/25/2011 10:07:33A1 SAN J( _UIN COUNTY ENVIRONMENTAL HE7 'H DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 7/25/2011 <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 />LODI, CA 95240 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-334-1680 <br />Mailing Address <br />88 CRYSTAL SPRINGS RD <br />MARKLEEVILLE, CA 961209508 <br />Care of <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 88 CRYSTAL SPRINGS RD <br />MARKLEEVILLE, CA 961209508 <br />Care of MAINLAND NURSERY INC <br />Location Code 99 - UNINCORPORATED A <br />BOS District 004 - VOGEL, KEN <br />APN 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 7/25/2011: $1,399.00 <br />Program/Element and Description <br />Record ID Employee ID and Name <br />Make changes/corrections in RED ink. O//( <br />INFORMATION CHANGE (date) O <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />WU>D,e) 10Vt !RRJ6A7— <br />/An( <br />t-✓, /, D' <br />/ g `777 N; 10 WJ6/2 SACRAA-4 -41,0 AL) <br />WgUTJt3Rl (7(�E, CA 9S25-6 <br />2CY9 346,? 660E <br />18777 A Lv t,UER SAC.-,A.)LACAI ZO RU <br />t'uLY70 Lii IyGC , C.,J 95- <br />-$'.A A A 6 <br />5- <br />sAAA6 <br />Hf/,/i Ji/Zr STyi?/aG� Lor <br />sin � <br />209 369 6806 <br />187-77 X1, Lot-L/e/Z S>aGRAAAC.Ar!"O AV <br />1�G1DOL�l2/OGE ,, � �SZS� <br />Alt Phone <br />Fax '209 369 692-3 <br />EMail : <br />70 'PO VER S i6EG- <br />209 T70 �t32f3 <br />it <br />New Account ID: <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />Status <br />(Circle One) <br />Transfer to Active/Inactve <br />New Owner? Delete <br />2832 - AST FAC 10 K-</=100 K GAL CUMULATIVEPRO515644 EE0001422 - ARIS CACAPIT Active Y N A t� D <br />ERSC - ELECTRONIC REPORTING STATE SURCHPR0532399 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: <br />Date / / <br />Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Tye Check Number Receive b <br />REHS: t`tZL Date /_/ l� Accountout: Date <br />COMMENTS: <br />\\eh-env\envision\reports\5021. rpt <br />