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Date run 12/15/1006 10:21:41) SAN JC 'IN COUNTY ENVIRONMENTAL HEI DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/15/2006 <br /> Record Selection Criteria: Facility ID FA0013507 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION r <br /> Owner ID OW0010636 New Owner ID <br /> Owner Name VAN RUITEN-TAYLOR WINERY <br /> Owner DBA VAN RUITEN-TAYLOR WINERY <br /> Owner Address 340 W HWY 12 <br /> LODI, CA 95242 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-334-5722 <br /> Mailing Address 340 W HWY 12 <br /> LODI, CA 95242 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013507 <br /> Facility Name VAN RUITEN-TAYLOR WINERY <br /> Location 340 W HWY 12 <br /> LODI, CA 95242 <br /> Phone 209-334-5722 <br /> Mailing Address 340 W HWY 12 <br /> LODI, CA 95242 <br /> Care of <br /> Location Code APN:05802005 <br /> BOS District 004 - SEIGLOCK, JACK SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0022609 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name VAN RUITEN-TAYLOR WINERY (Circle One) <br /> Account Balance as of 12/15/2006: $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 /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO517574 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0520870 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR,PR0517573 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,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: 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 Received by <br /> REHS: �iTi.ln)i { Date� / �.S / L> > Account out: 1V (n— Date d 6 <br /> COMMENTS: <br /> 0 T- <br /> +� 052(oq l 0 <br /> l �C, <br /> \\phs-ehsql-nt\apps\envisions\reports\5021.rpt <br />