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Date mn : 5/22/2003 10:00:41AI SAN JOt JIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by 1%r Pagel <br /> Facility Information as of 5/22/2003 <br /> Record Selection Criteria: Faculty ID FA0010042 <br /> Make changeslcorrections In RED Ink or pencil. <br /> INFORMATION CHANGE(date) <br /> 0RSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner l�• Case Number: H061 0NewOwri :7 DLJ OL8 ! <br /> Owner Name <br /> Owner DBA <br /> i <br /> Owner Address ��� ��.r <br /> Home Phone Not Specified �zny 1 f; <br /> Work/Business Phone ,7.7I- 6�ZnO <br /> Mailing Address <br /> ANANEI it-, CA-1226942446 v �T L <br /> Care of <br /> FACILITY FILE INFORMAT N <br /> ,l <br /> Facil ID FA0010042 1 <br /> FacilityN - �1 %P pn1L'� ( JL)✓�P , <br /> Location 923 S CHEROKEE LN <br /> LODI, CA 95240 <br /> Phone 2 i C SZ00 <br /> Mailing Address 2166 W BRG A IDWAY#557 t�-&,Zf 6?4-00 <br /> __,c <br /> Af•1 <br /> Care of 6FF =- <br /> Location Code SDI APN:047-390-06 <br /> BOS District 004 -SEIGLOCK, JACK SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> L <br /> Account ID q{�g (Z 0 O l7 0 New A unt ID: <br /> Mail Invoices to r1 b�� it Invoices to: Owner F Ity / Account <br /> Account Nam - - Imo3 o-cl o <br /> Account Balance as of 5/22/2003: $41 . l <br /> (Circle Or <br /> Transfer to Active/InacNe <br /> Program/Element and Description Record ID oyes ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONSNR PR0514141 EE0008389-DENNIS CATANYAG Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0512330 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPRO510042 EE0000000-HAZ MAT SJC DES Inactive 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 W 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 /> APPLICANTS SIGNATURE: Date `S- <br /> Program Records to be TRANSFERED: •$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$155.00= Amount Paid /Date <br /> Payment Type L,"� Check Number 00 R Received by "ASL <br /> REHS: Date_/ / Account out: -101— Date S / 2,2./ 03 <br /> COMMENTS: <br /> Fau'LL- a i5 no-t Dper1 -�D opZ4'L- 5-30- 03 <br /> N <br /> �P¢oR,n7eD) pa"I b : 5/3-7(03 _ 1--"(3t(03 <br /> 7 8 iSa — Mp`l 2 �Nn <br /> sop"jFa NEPPN°\v\s\°" <br /> \\Phs-ehsql-nt\apps\Envisions\Reports\5021. ESN\<aONM <br />