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Date run 831/2018 10:06:02AI' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 8/31/2018 <br />Record Selection Criteria: Facility ID FA0021534 <br />OWNER FILE INFORMATION Number of facilities for this owner: 8 <br />Owner ID <br />OW0017706 <br />Owner Name <br />JC Penney Corp. <br />Owner DBA <br />JCPENNEY CORP INC <br />OwnerAddress <br />6501 LEGACY DR <br />PLANO, TX 75024 <br />Home Phone <br />801-350-2376 <br />Work/Business Phone <br />972-431-1000 <br />Mailing Address <br />6501 Legacy Drive <br />Plano, TX 75024 <br />Care of <br />ROTHEY RICK <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0021534 10403185 <br />Facility Name <br />JC PENNEY #2692 <br />Location <br />2422 W Kettleman Ln <br />Lodi, CA 95242 <br />Phone <br />209-367-1221 x200 <br />Mailing Address 4703 Tidewater Avenue, Suite B <br />Oakland, CA 94601 <br />Care of Store Manager <br />Location Code 02 - LODI <br />Bos District 004 - WINN, CHARLES <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <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 />Account ID AR0038954 New Account ID: <br />Mail Invoices to Account Mail Invoices to: Owner / <br />Account Name PSI <br />Account Balance as of 8/31/2018: $0.00 <br />Facility / Account <br />(Circle One) <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-Regular-Primary Location PR0539188 EE0008709 - JAMIE LIMA Active Y N A VJ D <br />1921 - HMBP-Regular-Primary Location PR0542083 EE0008709 - JAMIE LIMA Inactive Y N A ,� D <br />2220 - SM HW GEN <5 TONS/YR PR0538438 EE0000030 -AARON HANG Active Y N A `lam D <br />91LLING 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 anc/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 <br />EHD Staff: Date / / Account out: Date <br />COMMENTS: <br />Invoice #: <br />