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Data run 7/27/2004 8:37:35Ah SAN JC ?UIN COUNTY ENVIRONMENTAL HEA- H DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 7/27/20tr4 Pagel <br /> Record Selection Criteria: Facility 10 FA0012458 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0009663 New Owner ID <br /> Owner Name SUTTER HOME WINERY INC <br /> Owner DBA SUTTER HOME WINERY <br /> Owner Address PO BOX 7248 <br /> ST HELENA, CA 945740248 <br /> Home Phone Not Specified <br /> Work/Business Phone 707-963-3104 <br /> Mailing Address PO BOX 248 <br /> ST HELENA, CA 945740248 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012458 <br /> Facility Name SUTTER HOME WINERY INC <br /> Location 1PKN JACOB BRACK <br /> /WAV LODI, CA 95240 <br /> Phone 209-368-5971 <br /> Mailing Address PO BOX 248 <br /> ST HELENA, CA 945740248 <br /> Care of <br /> Location Code 99 - UNINCORPORATED AREA APN:01115012 <br /> BOS District 004-SEIGLOCK, JACK SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0020315 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name SUTTER HOME WINERY INC (circle Oe) <br /> Account Balance as of 7/27/2004: $0.00 <br /> (Circle One) <br /> Transfer to Activelinactve <br /> Program/Element and Description Record ID Employee ID and Name status New Owner? Delete <br /> 2214-CaIARP FAC STATE SURCHARGE FEE PRO519005 EE0009999-SITE UNASSIGNED Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PRO516098 EE0009999-SITE UNASSIGNED Active Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PR0520830 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPR0516099 EE0009999-SITE UNASSIGNED Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,Me undersigned owner,operator or agent of same,acknowledge that all she,ardi project specific,PHS/EHD howdy charges associated wim Mis <br /> facility or activity will be billed to the party identified as Me OWNER on this form. I also certify Mat all operations will be performed in accordance with all applicable Ordinate Codes and/or Standards and <br /> State andlor 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: Date / ! Account out: Date_/ / <br /> COMMENTS: <br /> \\Phs-ehsql-nt\apps\Envisions\Reports\5021.rpt <br />