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Date run 5/24/2017 3:51:58PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 5/24/2017 <br />Record Selection Criteria: Facility ID FA0022744 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0020534 <br />Owner Name <br />Golden State Supply LLC <br />Owner DBA <br />730 S BECKMAN RD STE C <br />Owner Address <br />730 S BECKMAN RD C <br />Phone <br />LODI, CA 95240 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />919-573-3000 <br />Mailing Address <br />PO Box 26006 <br />Location Code <br />Raleigh, INC 27611 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0022744 10419802 <br />Facility Name <br />CQ OF LODI #7014 <br />Location <br />730 S BECKMAN RD STE C <br />LODI, CA 95240 <br />Phone <br />209-369-4395 x <br />Mailing Address <br />5008 Airport Road <br />Roanoke,VA 24012 <br />Care of <br />CARQUEST Auto Parts #7014 <br />Location Code <br />BOS District <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0041685 <br />Mail Invoices to Account <br />Account Name Micah Thompson <br />Account Balance as of 5/24/2017: $0.00 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />1 SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax _ <br />EMail : <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1921 - HMBP-Regular-Primary Location PR0539758 EE0008709 - JAMIE LIMA Active Y N A D <br />2220 - SM HW GEN <5 TONS/YR PR0539757 EE9999998 - ONE VACANTI Active Y N A 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 facility <br />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 Ordinance Codes and/or Standards and State and(or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: " $25.00 = Amount Paid Date / ! <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Tye, Check Number Received y <br />EHD Staff: `( AM Date _/ /�7 Account out: Date <br />COMMENTS: Invoice #: <br />P <br />