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Date and 110/17/2016 8:50:42A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 015021 <br />Run by . Pagel <br />Facility Information as of 10/17/2016 <br />Record Selection Catena: Facility ID FA0014882 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0011888 <br />Owner Name <br />t-Afbft`�N <br />Owner DBA <br />330 E KETTLEMAN LN <br />Owner Address <br />330 E KETTLEMAN LN <br />Phone <br />LODI, CA 95240 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />^^^ 366 , -,T <br />Mailing Address <br />330 E KETTLEMAN LN <br />Location Code <br />LODI, CA 95240 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0014882 <br />Facility Name <br />Location <br />330 E KETTLEMAN LN <br />LODI, CA 95240 <br />Phone <br />Mailing Address <br />330 E KETTLEMAN LN <br />LODI, CA 95240 <br />Care of <br />Location Code <br />SOS 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 />Account ID AR0025408 <br />Mail Invoices to Owner <br />Account Name J{tN <br />Account Balance as of 10/17/2016: $0.00 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />1 SSN / Fed Tax ID : <br />�&t <br />ID 5AJOM-71o' Ci <br />t uoxr G c4 <br />W C1 U q —ZZR <br />I CLn 1 CGOI.c.n 1 1 iP, <br />%1) %-W <br />Alt Phone <br />Fax <br />El <br />Mail Invoices to: <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Thmsferto Activellnacive <br />,LryP�`�/li lament and Description Record ID Employee ID and Name Status New Owner? Delete <br />194"1 - HMBP-Regular-Primary Location PR0521898 EE0008709 - JAMIE LIMA Inactive Y N I D <br />��/BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHSrEHD hourly charges associated with this facility <br />or activity will be billed to the party idenl as the OWNER on this form. I also certify that all operations will be pertormed in accordance with all applicable Ordinance Codes andlor Standards and State andlor <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 Racal <br />EHD Staff: l/1� Date / _/1 Account out: Date 0 <br />COMMENTSI <br />Invoice# <br />3u Vr, NS 0-C4YOWYV•. <br />ply. ya Pry waAi 6Lt Siar"01 Q �6 %S 0'cc6Lqj''i. $ I ZZZ .00 <br />