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Date run 11/13/2014 8:50:31A SAN JC&IN COUNTY ENVIRONMENTAL HEA16 DEPARTMENT Repor1#5021 <br /> Run by Pagel <br /> Facility Information as of 11/13/2014 <br /> Remold Selection Criteria: Facility ID FA0017920 <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: 66 SSN/Fed Tax ID <br /> Owner ID OW0000031 New Owner ID <br /> Owner Name LODI UNIFIED SCHOOL DISTRICT <br /> Owner DBA LODI UNIFIED SCHOOL DISTRICT <br /> Owner Address 1305 E VINE ST <br /> LODI, CA 95240 <br /> Home Phone 209-331-7159 <br /> Work/Business Phone 209-331-7121 <br /> Mailing Address 1305 E VINE ST <br /> LODI, CA 95240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017920 10186695 <br /> Facility Name LODI USD-RONALD E MCNAIR HIGH SCH <br /> Location 9550 RONALD E MCNAIR WAY <br /> STOCKTON, CA 95210 <br /> Phone 209-953-3282 x <br /> Mailing Address 1305 E VINE ST <br /> LODI, CA 95240-3145 <br /> Care of RONALD E MCNAIR HIGH SCHOOL <br /> Location Code 01 -STOCKTON Alt Phone <br /> SOS District 003- BESTOLARI DES Fax <br /> APN 08406016 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name RONALD E MCNAIR HIGH SCHOOL <br /> Title <br /> Day Phone 209-953-3282 <br /> Night Phone 209-351-5798 Cell <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0031430 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name LODI USD-RONALD E MCNAIR HIGH SCH (Circle One) <br /> Account Balance as of 11/13/2014: $53.25 <br /> (Circle One) <br /> Transferto Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Omer? Delete <br /> 1632-EXEMPT FOOD PR0526471 EE0005362-NICHOLAS WIESEMAN Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PRO528021 EE0000006-HAZA SAEED Active Y N A I D <br /> 2220-SM HW GEN<5 TONSNR PR0539594 EE0000005-FATINAH ZAREEF Active Y N A I D <br /> 3616-PUBLIC POOUSPA-EXEMPT PRO526560 EE0006362-NICHOLAS WIESEMAN Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0531994 Inactivc Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,me undersigned owner,operator or agent of same,acknowledge that all site,and/or project speoft,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party,identified as the OWNER on this form. Ialso certify that all operations will be performed in accordance with all applicable Ordinance Codes ander Standards and State ander <br /> Federal Lem. <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 /> REHS: Date / / Account out: Date <br /> COMMENTS: <br />