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Date run 12/20/2016 1:21:40P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 12/20/2016 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 Inactive Owner Address 1331 S HAM LN EE0000000 - HAZ MAT SJC OES LODI, CA 95242 Home Phone Not Specified Work/Business Phone 209-333-6740 Mailing Address 1331 S HAM LN LODI, CA 95242 Care of BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andlor project specific, PHS/EHD hourly charges associated with this facility FACILITY FILE INFORMATION Facility ID / CERS ID FA0009475 10182703 Facility Name Location 1490 W CENTURY BLVD LODI, CA 95242 Phone 209-333-6740 x0 Mailing Address 1331 S HAM LN LODI, CA 95242 Care of Location Code 02 - LODI Bos District 004 - WINN, CHARLES APN 06010006 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0016475 Mail Invoices to Owner Account Name CITY OF LODI Account Balance as of 12/20/2016: $0.00 Program/Element and Description Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : Q Alt Phone Fax EMail : Record ID Employee ID and Name Mail Invoices to: New Account ID: : Owner / Facility / Account (Circle One) (Circle One) Transfer to Active/Inactve Status New Owner? Delete 1920 - HMBP-Common Materials PR0519666 EE0008709 - JAMIE LIMA Active Y N A I D 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511763 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FE PR0509475 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D 2840 -AST EXEMPT FAC < 1,320 GAL PR0528452 EE0001422 -ARIS VELOSO Inactive Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARGI PRO532717 Inactive Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andlor 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 andlor 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 TyRa Check Number Received OYIA EHD Staff: la�l(Y�� Date �_/W /_Lip Account out: Date 12—/ .2-01 COMMENTS: Invoice #: