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Date run 2/8/2016 8:42:39AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 2/8/2016 <br />Record Selection Criteria: Facility ID FA0022164 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID OW0018248 <br />Owner Name <br />Philip Lange <br />Owner DBA <br />OwnerAddress <br />1298 W JAHANT RD <br />ACAMPO, CA 95220 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-479-1614 <br />Mailing Address <br />1298 W Jahant Rd <br />Acampo, CA 95220 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0022164 10417303 <br />Facility Name Felipe Shop <br />Location 23657 N LOWER SACRAMENTO RD <br />Acampo, CA 95220 <br />Phone 209-339-4055 x <br />Mailing Address 1298 W Jahant Rd <br />Acampo, CA 95220 <br />Care of LangeTwins <br />Location Code <br />BOS District <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 changesicorrections 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 AR0040384 New Account ID: : <br />Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br />Account Name Philip Lange (Circle One) 40% <br />Account Balance as of 2/8/2016: $938.00 <br />°�fie ne) <br />�n 1 Transfer A rve�In ctve <br />�69r�rr �ement and Description Record ID Employee ID and Name p//t /(�, Status New 0wne Dejj e <br />� fill HMBP-Regular-Primary Location PR0539209 EE0008709 / W SA Active Y N A D <br />2220 - SM HW GEN <5 TONS/YR PR0538349 EE0001422 - ARIS VELOSO 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, PHSrEHD 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 andror <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 Received by <br />EHD Staff: Date / /�� Account out: t,6 Date <br />COMMENTS: Invoice #: <br />