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Date run 1/30/2017 3:14:55PIv SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 05021 <br /> Paget <br /> Ran by Facility Information as of 1/30/2017 <br /> Record Selection Criteria: Facility ID FA0017951 <br /> Make changeslcorrections 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 OW0014747 New Owner ID <br /> Owner Name LOUIE J SOARES <br /> Owner DBA 4 US Yl <br /> Owner Address 400 N CLUFF AVE <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-334-0617 <br /> Mailing Address 400 N CLUFF AVE#A <br /> LODI, CA 95240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017951 10186721 <br /> Facility Name PP S LA I hG <br /> Location 400 N CLUFF AVE#A <br /> LODI, CA 95240 <br /> Phone 209-334-0617 x <br /> Mailing Address 400 N CLUFF AVE#A <br /> LODI, CA 95240 <br /> Care of Gene Takeuchi <br /> Location Code 02 - LODI Alt Phone <br /> Bos District 004-WINN, CHARLES Fax <br /> APN 04934014 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0031484 NewAccount ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name OLYMPIC TUNE/STREET RODS PLUS (Circle One) <br /> Account Balance as of 1/30/2017: $615.00 <br /> (Circle One) <br /> Transfer to Achwellnactve <br /> ProgranvElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0526510 EE0008709-JAMIE LIMA Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0526848 EE0000006-HAZA SAEED Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0533795 Inactive Y N A 1 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT'. I,the undersigned owner,operator or agent of same,a&nowlwge that all site,andor project specific.PHS'EHD hourly charges associated with this facility <br /> or activity wilt be billed to the party,identified as the OWNER on this form. I also certify that all operations will be pertomed in accordance with all applicable Ordnance Codes andor Standards and State andor <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 r <br /> EHD Staff: 1t1 v�"1 a Date ILL/ 30 / Account out: Date L/ Z 117COMMENTS: <br /> Invoice#: <br /> ��(� <br /> y��"�� ss <br /> fUVL� r ' "''vd l'�'x(�.{ Y�rNI►V(i V r"" <br /> ' U (J <br />