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Date run 4/20/2015 11:05:01AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 4/20/2015 <br /> Record Selection Criteria: Facility ID FA0011268 <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 OW0009268 Case Number: H09543 New Owner ID : <br /> Owner Name -LEST IER-GARY iii()✓) A 0�tnC_ fo <br /> Owner DBA -DONS-Mk1FFLER-&-BRAKE SVC' 1 <br /> Owner Address NI ! r-rrnrwrG l qtr 71 �Iw n e� �ry� <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone g49..32- - 7,,2 <br /> Mailing Address z ti 1'q cbm ex <br /> -tAA-9541 67A G(5Z0q <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0011268 10184133 <br /> Facility Name 1 nm�m iss 5 Ail <br /> Location .2G-N-O}{ER-E)}({E LN A <br /> LODI, CA 95240 <br /> Phone_2.gq_3-3 _29� <br /> Mailing Address-Pe-66%(133— Z <br /> t-�91-Grp-9L49� CLA 9'5-2-96 <br /> Care of <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 04321027 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 AR0018268 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name LESHER, GARY (Circle One) <br /> Account Balance as of 4/20/2015: $0.00 <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-Reqular-Primary Location PRO520794 EE0008709-JAMIE DE LA ROSA Inactive Y N @ I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513556 EE0000000-HAZ MAT SJC OES Inactive Y N I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0511268 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532333 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor 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: 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 by <br /> REHS: DAQQ i_ Date /ZD/f_ Account out: _ Date / / <br /> COMMENTS: <br />