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Date run 6/16/2008 2:54:56PN SAN.ftIN COUNTY ENVIRONMENTAL I-IL1111 DEPARTMENT Report#5021 <br /> Run;.Y Pagel <br /> Facility Information as of 6/16/200 <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 SSN/Fed Tax ID <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 A 7n ,,, <br /> Location 340 W HWY 12 T S <br /> LODI, CA 95242 <br /> Phone 209-334-5722 x0 <br /> Mailing Address 340 W HWY 12 <br /> LODI, CA 95242 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 05802005 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone 209-339-8467 <br /> Night Phone <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 6/16/2008: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New OwneO Delete <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPR0517574 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 SURCHAR1PR0517573 EE0000000-HAZ MAT SJC OES Inactive Y N A D <br /> 2836-AST FAC>/=100 M+ 1 GAL CUMULATIVE PR0526710 EE0004636-GARRETT BACKUS 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 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 Recei <br /> REHS: Date / / Account out: Date / <br /> COMMENTS: I <br /> Af,4 Lrjo <br /> \\phs-ehsql-nt\apps\envisions\reports\5021.rpt <br />