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Date run g/i8/2ptq 2:t0:56PA SAN JO>�JIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT <br /> Run by Report;Y5021 <br /> Facility Information as of 9/18/2014 Pagel <br /> Record Selection Criteria: Facility ID FA0022453 <br /> Make changesicorrections 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 OW0019877 New Owner ID <br /> Owner Name Bill Shinn <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-369-4292 <br /> Mailing Address P.O. Box 1051 <br /> Woodbridge, CA 95258 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022453 10413202 <br /> Facility Name J & J Shinn Ranch Shop <br /> Location 21500 N Davis Rd <br /> Lodi, CA 95242 <br /> Phone 209-369-4903 x <br /> Mailing Address P.O. BOX 1051 <br /> Woodbridge, CA 95258 <br /> Care of J &J Shinn Ranch <br /> Location Code Alt Phone <br /> BOIS District Fax <br /> APN 013-080-410-001 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 AR0041096 New Account ID: <br /> Mail Invoices to Facility pp �/� Mail Invoices to: Owner / Facility / Account <br /> Account Name J & J Sch Shop �iQ1 06 7 d n� (Circle one) <br /> ccoount Balance as of 9/18/2014 $615.0 $ J ` C) U/" (Circe one) <br /> 1_^ s,1(6 Transfer to AUivedriecrie <br /> /Element and <br /> Descnpdon Record ID Employee ID and Name status New OwneR Delete <br /> 1921 -HMBP-Regular-Zary Location PRO539264 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> NGand COMPLIANCE ACKNO E 4MENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor proles specific,PHSIEHD hourly charges associated with this facility <br /> or activity will W billed to the party identified as the OWNER on this form. I also certify that all operations will ba performed in accordance with all applicable Ordinance Codes andor Standards and State ands <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date / I <br /> Paymentp Check Number Recei y <br /> RENS: �� Date / / Account out: p. Date /,&;k 7,L4 <br /> COMMENTS: <br /> '(11,15 is 11581 y)ot a l�u�i►�e� f <br /> 4)m+ oq dee <br />