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Date run 1/19/2016 3:01:14PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 1/19/2016 <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 />Owner Address <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 x <br />Mailing Address <br />4703 Tidewater Avenue, Suite B <br />Oakland, CA 94601 <br />Care of <br />Virginia A McCoy (Store Manager) <br />Location Code <br />02 - LODI <br />BOS District <br />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 <br />Mail Invoices to Account Mail Invoices to: <br />Account Name PSI <br />Account Balance as of 1/19/2016: $0.00 <br />New Account ID: : <br />Owner / 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 DE LA ROSA Active Y N A 0 D <br />2220 - SM HW GEN <5 TONS/YR PR0538438 EE0005642 - MICHELLE HENRY Active 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, PHSIEHD 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 <br />EHD Staff: �- Date / / Account out: Date // <br />COMMENTS: Invoice #: <br />I ll ��" i coJis me, "aw rq ��� Plam��Y' <br />