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Date run 9/21/2004 11:51:28AI SAN JgZUIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report' i121 <br /> Run by Pagel <br /> Facility Information as of 9/21/2004 <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 <br /> Owner ID OW0006171 New Owner ID <br /> Owner Name LODI CITY OF <br /> Owner DBA <br /> Owner Address 104 N SCHOOL ST <br /> LODI, CA 95241 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-333-6906 <br /> Mailing Address PO BOX 3006 <br /> LODI, CA 95241 <br /> Care of 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 APN: <br /> BOS District 004- SEIGLOCK, JACK SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0021537 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name WHITE SLOUGH WATER POLLUTION CONTRO (Circle One) <br /> Account Balance as of 9/21/2004: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> ro ram/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> t 26 RWOCB CLEAN UP SITE(SLIC) PR0516806 EE0000997-HARLIN KNOLL Active Y N A I D <br /> BIL G 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: *$155.00= Amount Paid Date ! / <br /> Payment Type Check Number Received by <br /> REHS: � T�Lk� Date Account out: Date <br /> COMMENTS: <br /> \\phs-ehsql-nt\apps\envisions\reports\5021.rpt <br />