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Date mn 5/19/2017 7:57:30AR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 4t5021 <br /> Run by Pagel <br /> Facility Information as of 5/19/2017 <br /> Record Selection Criteria: Facility ID FA0012731 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0009917 New Owner ID <br /> Owner Name Mike Brandt <br /> Owner DBA SAN JOAQUIN CHROME <br /> Owner Address 1709 W ROSE ST <br /> LODI, CA 95240 <br /> Home Phone 209-463-7540 <br /> Work/Business Phone 209-365-9694 <br /> Mailing Address 910 Black Diamond Wy unit B <br /> Lodi, CA 95240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0012731 10451968 <br /> Facility Name San Joaquin Chrome <br /> Location 910 BLACK DIAMOND WAY UNIT B <br /> Lodi, CA 95240 <br /> Phone 209-365-9694 x <br /> Mailing Address 910 Black Diamond unit B <br /> Lodi, CA 95240 <br /> Care of Mike Brandt <br /> Location Code 02 -LODI Alt Phone <br /> BOS District 004-WINN, CHARLES Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0021249 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Mike Brandt (Circle One) <br /> Account Balance as of 5/19/2017: $0.00 <br /> (Circle One) <br /> Transfer to Activsumachnt <br /> Progra brElemenl and Description Record ID Employee ID and Name Status New 01 Delete <br /> 1921 -HMBP-Regular-Primary Location PRO520953 EE0008709-JAMIE LIMA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0517547 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2247-RCRA GEN 5<25 TONS PR0516668 EE9999998-ONE VACANTI Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO516670 EE0007289-ALISON YOUNGBLOOD Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533695 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anchor project specific,PHSEHD hourly charges associated with this facility <br /> or activity will be billed to the party identi ool as the OWNER on this form I also canny that all operations will be performed In accordance with all applicable Ordinance Codes andor standards and Stale anchor <br /> Federal Laws, <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date / / <br /> Payment Type ���Check Number Received b !' <br /> EHD Staff_:`` (� /x. Date / / Account out: Date / r -� /1 -7 <br /> COMMENTSit,1` <br /> Invoice#: <br />