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Date run : 11/9/00 11:22:39AM SAN4JAQUIN COUNTY PUBLIC HEALTH SEIIfES Report #: 0002 <br /> Run by VPEDRAZA Facility Information as of 11/9/00 Page #: 1 <br /> Record Selection Criteria: FacilityID FA0003768 <br /> Record ID <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE (date) <br /> v <br /> OW HIP C�ANGE (date) <br /> OWNER FILE INFORMATION Vim- <br /> Owner ID: OW0002798 NewOwner ID <br /> Owner Name: <TAVI OR. ARNIF d <br /> Owner DBA: TArYL-O.R-T9LJRS-- MIX <br /> OwnerAddress: 330 E KETTLEMAN I1 VA <br /> LODI, CA 95240- _ Cl 2" 2 <br /> Home Phone: 209-134-400s L1c�9 — 9 — <br /> Work/Bussness Phone: 2Q9-334.40Q5 7-n C/ _�'�—7 � d <br /> Mailing Address: -PO$Q)(_523 <br /> Careof: TA`,-,.,AGR,-ARN4 R <br /> FACILITY FILE INFORMATION <br /> Facility to: FA0003768 T �. <br /> Facility Name: -i,^YLDR-T-Ob4' 9- K0 a I C'a-'I(b r <br /> Location: 330 E KETTLEMAN LN <br /> LODI, CA 95240 p <br /> Phone:-209-334-4905 <br /> Mailing Address: R9-BOX 523— C - <br /> 6 - Z— <br /> Care of: -T-AYLoR-T@URS P- c n Y <br /> Location Code: 02 - LODI APN: <br /> BOS District: 004- SEIGLOCK, JACK SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0003347 New Account to:: <br /> Mail Invoices to: Facility Mail Invoices to: Owner/ Facility/Account <br /> Account Name: TAYLOR TOURS (Circle One) <br /> Account Balance as of 11/9/00: $0.00 <br /> (Circle One) <br /> UST(s) Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status Linked New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0514440 EE0006213-PEDRAZA Active Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84) PR0232267 EE0006213-PEDRAZA Inactive 3 Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FI PR0507450 EE0006213-PEDRAZA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO513157 EE0000000-SJC OES Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agentof same,acknowledge thata6 site,and/or <br /> project specific,PHS/EAD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on this <br /> form. I also certify thatall operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and State and/or Federal <br /> Laws. <br /> APPLICANT'S SIGNATURE: Date I I <br /> Program Records to be TRANSFERED: '$0.00= Amount Paid Date / / <br /> Water System to be TRANSFERED: '$150.00= Amount Paid Date <br /> Payment Type Check Number Receipt Number Received by <br /> REHS: Date / / Account out: f Date__z <br /> �,l�,lczJ Q .�G(P�•c���irL/ <br /> 1.0.0.89.00 <br />