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Date run 3/13/2017 4:45:05PA SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 3/13/2017 <br />Record Selection Criteria: Facility ID FA0005457 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0000129 <br />Owner Name <br />City of Lodi <br />Owner DBA <br />Owner Address <br />1331 S HAM LN <br />LODI, CA 95240 <br />Home Phone <br />209-333-6878 <br />Work/Business Phone <br />209-333-6800 <br />Mailing Address <br />PO Box 3006 <br />Lodi, CA 95240 <br />Care of <br />Attn: Andrew Richle <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0005457 10181827 <br />Facility Name <br />LODI CITY WELL #5 <br />Location <br />401 N MILLS AVE <br />LODI, CA 95242 <br />Phone <br />209-333-6800 x <br />Mailing Address <br />1331 S HAM LN <br />LODI, CA 95242 <br />Care of <br />CITY OF LODI <br />Location Code <br />02 - LODI <br />BOS District <br />004 - WINN, CHARLES <br />APN <br />02908206 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0005989 <br />Mail Invoices to Account <br />Account Name CITY OF LODI <br />Account Balance as of 3/13/2017: $0.00 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />24 SSN / Fed Tax ID <br />New Owner ID : <br />p 6ox 3o0 <br />—Ic1/O <br />Alt Phone <br />Fax <br />EMail : <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1921 - HMBP-Reqular-Primary Location PR0513004 EE0008709 - JAMIE LIMA Active Y N A I D <br />2381 - UST FACILITY (BEFORE 1/84) - obsolete PR0502465 EE9999998 - ONE VACANT1 Inactive Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PRO510716 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />2840 - AST EXEMPT FAC < 1,320 GAL PR0528450 EE0000030 - AARON HANG InactivE Y N A I D <br />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 <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 and/or Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />EHD Staff: <br />COMMENTS: <br />Date <br />" $25.00 = Amount Paid Date <br />Amount Paid Date <br />Received by <br />Account out: Date <br />Date <br />Invoice #: <br />a ��hwlo Pte- rn� <br />