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Dale run 2/22/2018 10:56:25AP SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/22/2018 <br /> Record Selection Criteria: Facility ID FA0006300 <br /> Make changes/corrections 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 OW.p0�0pV17�NI048 New Owner_JD : _ <br /> Owner Name 61RA J ❑k !- 4EEf NC Edo I.�nc <br /> Owner DBA <br /> Owner Address 686 E LOCKEFORD AVE <br /> LODI, CA 95240 <br /> Home Phone 2G&Qg3_gZ_4— <br /> Work/Business Phone ^^.�..^-,-36g FddfL <br /> Mailing Address-Pe-BQjE-26jtq, (,{ ' <br /> Care of <br /> FACILITY FILE INFORMATION - 7 <br /> Facility ID/CER —1 A00 00 10182077 " <br /> Facili Name -€NG UEER4NG_ <br /> o ation g6 E LOC KEFORD AVE <br /> LODI, CA 95240 <br /> one 2' 9.368-x440—x—� V X — <br /> Mailing d ress .7.2_ b <br /> LODI, CA 95241-2672 ] <br /> Ca aof �r.6aq-�q pe&R49 <br /> L ation ode 02 - LODI Alt Phone <br /> BOIS Di trict 004-WINN, CHARLES Fax <br /> PN 04905003 �.?S EMail: <br /> EMERGENCYIN IFICTION CONTACT INFORMAT <br /> Cont t N e <br /> Ile <br /> Day Pho e <br /> Night Pho e <br /> ACCOUNTS RECEIVABLE FIL ION <br /> Account ID AR0007513 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name CRAYCntJ FNlrinlr_� (Circle One) <br /> Account Balance as of 2/22/2018: $0.00 <br /> (Circle One) <br /> Transferlo Activellnactve <br /> gram/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4421=HMBP-Regular-Primary Location PR0527524 EE0008709-JAMIE LIMA Active Y N A D <br /> 2220-SM HW GEN<5 TONS/YR PR0528798 EE9999998-ONE VACANTI Active Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PRO604748 EE9999998-ONE VACANTI Inactive Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATIVE PRO528797 EE0000030-AARON HANG Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO533944 Inactive 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,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 ands Standards and State and'or <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 <br /> Payment Type• Check Number Received by <br /> EHD Staff: Date / / Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />