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Date run 5/24/2017 9:44:10AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 5/24/2017 <br />Record Selection Criteria: Facility ID FA0012563 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0001693 <br />Owner Name <br />Ross Dress For Less Inc. <br />Owner DBA <br />Lodi, CA 95240 <br />Owner Address <br />5130 HACIENDA DR FLOOR <br />Mailing Address <br />DUBLIN, CA 94568-7579 <br />Home Phone <br />925-965-4526 <br />Work/Business Phone <br />925-965-4831 <br />Mailing Address <br />5130 Hacienda Dr <br />Bos District <br />Dublin, CA 94568-7579 <br />Care of <br />LICENSING <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0012563 10508965 <br />Facility Name <br />Ross Dress For Less #0477 <br />Location <br />340 W Kettleman Ln <br />Lodi, CA 95240 <br />Phone <br />209-369-1386 x <br />Mailing Address <br />5130 Hacienda Dr <br />Dublin, CA 94568-7579 <br />Care of <br />Ross Dress For Less Inc. <br />Location Code <br />02 - LODI <br />Bos District <br />004 - WINN, CHARLES <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name FOLDESSY, MARIANNE <br />Title <br />Day Phone 510-505-4583 <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />8 SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />Account ID AR0020687 <br />Mail Invoices to Account Mail Invoices to <br />Account Name KATHY T H/LICENSING DEPT <br />Account Balance as of 5/24/2017: $3 .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 />1615 - RETAIL MKT 301-2000 SQ FT (PREPKGD/LTD PR PR0516336 EE0001084 - STEPHANIE RAMIREZ Active Y N A � D <br />1921 - HMBP-Reqular-Primary Location PR0541822 EE0008709 - JAMIE LIMA Active Y N A 1 D <br />2220 - SM HW GEN <5 TONS/YR PR0539585 EE9999998 - ONE VACANT1 Active Y N A D <br />BILLING 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 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 Tye Check Number Received b <br />EHD Staff: I-11 MCL, Date / /17—Account out: Date <br />COMMENTS: <br />V� 1 C" m� rq ur�� +W�� <br />Invoice #: <br />