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Date run 2/10/2017 3:24:21PIV SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 2/10/2017 Record Selection Criteria: Facility ID FA0009475 OWNER FILE INFORMATION Number of facilities for this owner : 6 Owner ID OW0007474 Case Number: H04385 Owner Name CITY OF LODI Owner DBA Night Phone OwnerAddress 1331 S HAM LN LODI, CA 95242 Home Phone Not Specified Work/Business Phone 209-333-6740 Mailing Address 1331 S HAM LN LODI, CA 95242 Care of FACILITY FILE INFORMATION Facility ID / CERS ID FA0009475 10182703 Facility Name LODI CITY WELL #16 Location 1490 W CENTURY BLVD 22 - HAZ MAT BUSINESS PLAN AUTHORIZATION LODI, CA 95242 Phone 209-333-6740 Mailing Address 1331 S HAM LN ERSC - ELECTRONIC REPORTING STATE SURCHARGE LODI, CA 95242 Care of Location Code 02 - LODI BOS District 004 - WINN, CHARLES APN 06010006 EMERGENCY NOTIFICATION CONTACT INFORMATION Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : Alt Phone Fax - EMail : Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0016475 New Account ID: Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account Account Name CITY OF LODI (Circle One) Accqunt Balance as of 2/10/2017: $164.00 \ (Circle One) Transferto Active/Inactve g /Element and Description Record ID Employee ID and Name Status New Owner? Delete 1 0 - HMBP-Common Materials PR0519666 EE0008709 - JAMIE LIMA Active Y N A I D 22 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511763 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F1 PR0509475 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D 2840 -AST EXEMPT FAC < 1,320 GAL PR0528452 EE0000030 -AARON HANG Inactive Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARGE PR0532717 Inactive Y N A I D 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 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 andor Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Received by EHD Staff: lii m ni,_ Date /_ 10 / L:7 Account out: Date COMMENTS: �, CSV iW 1 1