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Date ren 8/28/2008 4:21:47PN SAN JUIN COUNTY ENVIRONMENTAL HE DEPARTMENT Report#5021 <br /> Run by y Pagel <br /> • Facility Information as of 8/28/20 8 <br /> Record Selection Criteria: Facility ID FA0012817 <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 OW0006171 New Owner ID <br /> Owner Name LODI CITY OF <br /> Owner DBA <br /> Owner Address VJ1 _ <br /> LODI, CA 96244— <br /> Home Phone Not Specified <br /> Work/Business Phone 209-3-3 . 1— 3 3 3— (o a a <br /> Mailing Address f9() B DX--3ee& -c— <br /> LODI, <br /> LLODI, CA moi-- )L <br /> Care of <br /> CITY OF LODI <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012817 <br /> Facility Name WHITE SLOUGH WATER POLLUTION CON- <br /> Location 12751 N THORNTON RD <br /> LODI, CA 95241 <br /> Phone 209-333-6740 <br /> Mailing Address PO BOX 3006 <br /> LODI, CA 952411910 <br /> Care of CITY OF LODI <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name CITY OF LODI <br /> Title <br /> Day Phone 209-333-6740 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION S� a-iCAdJ <br /> Account ID AR0021537 New Account ID: <br /> Mail Invoices to -- o (,J h�- Mail Invoices to: Owner Facility / Account <br /> Account Name WHITE SLOUGH WATER POLLUTION CONTRO (Circle One) <br /> Account Balance as of 8/28/2008: $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 /> 2965-WATER QUALITY SITE PROJECT PRO516806 EE0000997-HARLIN KNOLL 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 TRANSFER� *$372.00= Amount Paid Date <br /> Payment Type ✓ Check Number Received by <br /> REHS: �- ✓� �l—c,� Date / / Account out: G— Date / ZS / D g <br /> COMMENTS: <br /> \\phs-ehsql-nt\apps\envisions\reports\5021.rpt <br />