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Date run 8/1/2017 9:58:22AM SAN JOAQ�UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Run by Report#5021 <br /> Facility Information as of 8/1/2017 Pagel <br /> Record Selection Crite a: Facility ID FA 0545 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNER FELE INFORMATION Number of facilities for this owner: 24 OWNERSHIP CHANGE(date) <br /> SSN/Fed Tax ID <br /> Owner ID OW0000129 <br /> New Owner ID <br /> Owner Name City of Lodi -Attn:Andrew Richle <br /> Owner DBA <br /> OwnerAddress 1331 S HAM LN <br /> LODI, CA 95240 <br /> Home Phone 209-333-6878 <br /> Work/Business Phone 209-333-6841 <br /> Mailing Address 1331 S. Ham Lane 95242 <br /> Lodi, CA 95242 <br /> Care of Attn:Andrew Richle <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0005458 10181829 <br /> Facility Name LODI CITY WELL#13 <br /> Location 520 S LOWER SACRAMENTO RD <br /> LODI, CA 95240 <br /> Phone 209-333-6706 x <br /> Mailing Address 1331 S HAM LN <br /> LODI, CA 95240 <br /> Care of CITY OF LODI <br /> Location Code 02 - LODI Alt Rhone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 02710101 EMaV <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0005990 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner 1 Facility f Account <br /> Account Name LODI CITY WELL#13 (Circle One) <br /> Account Balance as of 8!112017; $0.00 <br /> (Circle One) <br /> ProgramlElement and Desc ption Transfer to Activellnacive <br /> Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PR0513007 EED008709-JAMIE LIMA Active Y N A Q D <br /> 2381 -UST FACILITY(BEFORE 1184)-obsolete PR0502467 EE9999998-ONE VACANTI Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAG STATE SURCHARGE R PRO510719 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2840-AST EXEMPT FAC < 1,320 GAL PR0528448 EE0000030-AARON HANG InactivE Y N A I D <br /> BILLING and COMPLIANCfE ACKNOWLEDGEMENT, I,the undersigned owner,operator or agent of same,acknowledge that all site,anal project specific,PHSlEHD 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 andlor Standards and State and/or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / 1 <br /> Program Records to be TRANSFERED: '$25,00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date-1-1 <br /> Payment Tye Check Number Received b <br /> EHD Staff: <br /> COMMENTS: Date 1_�f 7 Account out: Date�1 II� <br /> COM <br /> V `C_il at4 -e � Invoice#: <br />