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Date run 2/16/2016 9:54:10Ary SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 2/16/2016 <br />Record Selection Criteria: Facility ID FA0018388 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID OW0015107 <br />Owner Name <br />Owner DBA <br />MZ H6b"3f-0f-T13t4­E- <br />OwnerAddress <br />308 N CHEROKEE LN <br />LODI, CA 952402401 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-369-9315 <br />Mailing Address <br />308 N CHEROKEE LN <br />LODI, CA 95240-2401 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0018388 10186855 <br />Facility Name <br />Location 308 N CHEROKEE LN <br />LODI, CA 95240 <br />Phone 209-369-9315 x <br />Mailing Address 308 N CHEROKEE LN <br />LODI, CA 95240-2401 <br />Care of M.Z.gQR�r <br />Location Code 02 - LODI <br />Bos District 004 - WINN, CHARLES <br />APN 04130009 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0032435 <br />Mail Invoices to Owner <br />Account Name NOEL B TABORA <br />Account Balance as of 2/16/2016: $348.00 <br />Program/Element and Description <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID <br />Alt Phone <br />Fax <br />EMail : <br />Record ID Employee ID and Name <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/lnactve <br />Status New Owner? Delete <br />1920 - HMBP-Common Materials PR0527129 EE0008709 - JAMIE DE LA ROSA Active Y N A I D <br />2220 - SM HW GEN <5 TONS/YR PR0537646 EE0001422 -ARIS VELOSO Active Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGE PR0531783 Inactive Y N A I 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 Type Check Number Received by _ <br />EHD Staff: 12 � 2A-fA_ Date 7— -Account out: 05 Date <br />COMMENTS: <br />Invoice #: <br />