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Date run 4/22/2016 3:58:17PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by � Pagel <br /> . Facility Information as of 4/22/2016 , <br /> Record Selection Criteria: Facility ID FA0020102 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN 1 Fed Tax ID <br /> Owner ID OW0016503 Ngw O ner ID : <br /> Owner Name ('Jw�I <br /> Owner DBA ESTATE CRUSH <br /> Owner Address 2 W LOCKEFORD ST <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> WorklBusiness Phone 209-368-7595 <br /> Mailing Address 2 W LOCKEFORD ST . <br /> LODI, CA 95240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID!CERS ID FA0020102 10187513 <br /> Facility Name ESTATE CRUSH <br /> Location 2 W LOCKEFORD ST <br /> LODI, CA 95240 <br /> Phone 209-368-7595 x0 i <br /> Mailing Address 2 W LOCKEFORD ST <br /> LODI, CA 95240 <br /> Care of <br /> Location Code 02 - LODI AYKone <br /> BOS District 004-WINN, CHARLES Fax <br /> APN 04302505 EMaii: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0035868 New Account ID: <br /> ` Mail Invoices to Owner Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name kb <br /> (Circle One) <br /> Account Balance as of 412212016: $0.00 <br /> (Circle One) <br /> Transferto Active4nactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0531216 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO531891 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project speck,PHSfEHD 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 andror Standards and State and'or <br /> Federal Laws_ <br /> APPLICANT'S SIGNATURE: Date ! / <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date 1 ! <br /> Water System to be TRANSFERED: Amount Paid Date I I <br /> Payment Type Check Number Received by <br /> EHD Staff: a ___ Date 1�! Account out: �� _ Date 1 �� <br /> COMMENTS: <br /> Invoice#: <br /> 1 - D�C1S X110 <br /> 06 — at GA'kz�s � <br />