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Date run 10/3/2018 2:10:04PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 10/3/2018 Record Selection Criteria: Facility ID FA0009759 OWNER FILE INFORMATION Number of facilities for this owner : 1 Owner ID OW0007759 Case Number: H05346 Owner Name JIM MUNRO Owner DBA VIC MYERS INC OwnerAddress 320 S SACRAMENTO ST LODI, CA 95240 Home Phone Not Specified Work/Business Phone 209-339-0339 Mailing Address PO BOX 235 LODI, CA 95241 Care of FACILITY FILE INFORMATION Facility ID / CERS ID FA0009759 10182879 Facility Name VIC MYERS INC Location 320 S SACRAMENTO ST LODI, CA 95240 Phone 209-334-5700 x Mailing Address 320 S SACRAMENTO ST LODI, CA 95240 Care of JenniferAchee Location Code 02 - LODI BOS District 004 - WINN, CHARLES APN 04531004 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Cher Grenie Title office manager Day Phone 209-334-5700 Night Phone 209-333-0341 QQ ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0016759 Mail Invoices to Account Account Name JIM MUN O o� Account Balance as of 10/3/2018: 477.00 Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : Fax EMail : New Acco u nt I D: : Mail Invoices to: Owner / Facility / Account (Circle One) (Circle One) Active/Inactve Delete AI D A D A I D A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this facility 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 and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: ` $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Ty ei Check Number Received by E H D Staff: �,�Q/ Date / / Account out: Date �COMMENTS: s no l rm� IV) . Invoice #: 03 Transfer to Program/Element and Description Record ID Employee ID and Name Status New Owner? 1921 - HMBP-Regular-Primary Location PR0519853 EE0008709 - JAMIE LIMA Active Y N 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512047 EE0000000 - HAZ MAT SJC OES Inactive Y N 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0509759 EE0000000 - HAZ MAT SJC OES Inactive Y N ERSC - ELECTRONIC REPORTING STATE SURCHARGI PRO533492 Inactive Y N (Circle One) Active/Inactve Delete AI D A D A I D A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this facility 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 and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: ` $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Ty ei Check Number Received by E H D Staff: �,�Q/ Date / / Account out: Date �COMMENTS: s no l rm� IV) . Invoice #: 03