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Date run 10/18/2004 11:59:461 SAN JUIN COUNTY ENVIRONMENTAL HE ' �H DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/18 4 <br /> Record Selection Criteria: Facility ID FA0012587 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> Owner ID OW0003305 New Owner ID <br /> Owner Name OAK RIDGE WINERY, LLC <br /> Owner DBA OAK RIDGE WINERY LLC <br /> Owner Address PO BOX 440 <br /> LODI, CA 95241 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-369-4768 <br /> Mailing Address PO BOX 440 <br /> LODI, CA 95241 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012587 <br /> Facility Name OAK RIDGE WINERY LLC <br /> Location 6100 E HWY 12 <br /> LODI, CA 95240 <br /> Phone 209-369-4768 <br /> Mailing Address PO BOX 440 <br /> LODI, CA 95241 <br /> Care of OAK RIDGE WINERY LLC <br /> Location Code 99- UNINCORPORATED AREA APN: <br /> BOS District 004-SEIGLOCK, JACK SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0020777 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name OAK RIDGE WINERY LLC (Circle One) <br /> Account Balance as of 10/18/2004: $0.00 <br /> (Circle One) <br /> Transfer to Active/lnactve <br /> P /Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 296 - QCB CLEAN UP SITE(SLIC) PR0516379 EE0000997-HARLIN KNOLL Active Y N A I D <br /> BIL 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 /> acilit 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 nd/or Federal Laws. <br /> APP [CANT'S SIGNATURE: Date <br /> Progr m Records to be TRANSFERED: *$20.00= Amount Paid Date <br /> Water ystem to be TRANSFERED: *$155.00= Amount Paid Date / ! <br /> Payme t Type Check Number Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> 6 S- <br /> � 1 <br /> 6u. <br /> \\phs-ehsg]-nt\apps\envisions\reports\5021.rpt <br />