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Date run 4/22/2016 3:59:07PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 4/22/2016 <br /> Record Selection Cntena: Facility ID FA0019418 <br /> Make changesfcorrections 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 OW0015914 New Owner ID <br /> Owner Name BLUE SHIELD OF CALIFORNIA <br /> Owner DBA BLUE SHIELD OF CALIFORNIA <br /> OwnerAddress 4203 TOWN CENTER BLVD <br /> ELDORADO HILLS, CA 95672 <br /> Home Phone 916-350-7794 <br /> Work/Business Phone 209-371-3822 <br /> Mailing Address 3021 Reynolds Ranch Pkwy <br /> Lodi, CA 95240 <br /> care of FACILITIES <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0019418 10187229 <br /> Facility Name BLUE SHIELD OF CALIFORNIA <br /> Location 3021 REYNOLDS RANCH PKWY <br /> LODI, CA 95240 <br /> Phone 209-371-3822 x <br /> Mailing Address 10700 PRAIRIE LAKES DR <br /> EDEN PRAIRIE, MN 55344 <br /> care of Steven Tarkan <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 05865005 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> contact Name ATTN: FACILITIES <br /> Title <br /> Day Phone <br /> Night Phone 916-350-7794 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0034531 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility I Account <br /> Account Name BLUE SHIELD OF CALIFORNIA (Circle One) <br /> Account Balance as of 4/22/2016: $0.00 <br /> (Circle One) <br /> Transfer to AdivelInaetve <br /> Program/Element and Description Record ID Employee ID and Name Status New OwneR Delete <br /> 1626-RESTAURANT/BAR 101 +SEATS PRO529100 EE0009488-JEFFREY WONG Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PRO535625 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE PR0536018 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,ardor Project specific,PHVEHD 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 we,all applicable Ordinance Codas andor Standards and State and'or <br /> Federal Laws, <br /> APPLICANTS SIGNATURE: Date I / <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: Invoice#: <br />