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Date run 4/17/2017 8:53:33AK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 4/17/2017 <br />Record Selection Criteria: Facility ID FA0010505 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0008504 <br />Owner Name <br />WESTERN AREA POWER ADMN <br />Owner DBA <br />Active/Inactve <br />OwnerAddress <br />114 PARKSHORE DR <br />Delete <br />FOLSOM, CA 95630 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />916-353-4416 <br />Mailing Address <br />114 PARKSHORE DR <br />FOLSOM, CA 95630 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0010505 10183607 <br />Facility Name WESTERN AREA POWER ADMIN <br />Location 500 ROTH RD <br />LATHROP, CA 95330 <br />Phone 916-353-4416 <br />Mailing Address 114 PARKSHORE DR <br />FOLSOM, CA 95630 <br />Care of DISPATCH <br />Location Code <br />Bos District 003 - BESTOLARIDES, STEVE <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />2 SSN / Fed Tax ID <br />New Owner ID <br />IL <br />Alt Phone <br />Fax <br />EMail : <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0017505 <br />i <br />Mail Invoices to Account <br />Account Name C/O E IRONMEN' ALAFFA <br />Account Balance as of 4/17/20 : $355.90 <br />Program/Element and Description ' Record ID Employee ID and Name <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />1921 - HMBP-Regular-Primary Locatio--r PR0512793 EE0000009 - NICHOLAS LOEHRER <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0510505 EE0000000 - HAZ MAT SJC OES <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 andror <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />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 />EHD Staff: I/ ��� � 1—nehiZ J' Date-Zr)7Account out: t Date <br />COMMENTS: <br />Invoice #: <br />Me- <br />cl0!;ztt <br />(Circle One) <br />Transfer to <br />Active/Inactve <br />Status <br />New Owner? <br />Delete <br />Active <br />Y N <br />A D <br />Inactive <br />Y N <br />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 andror <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />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 />EHD Staff: I/ ��� � 1—nehiZ J' Date-Zr)7Account out: t Date <br />COMMENTS: <br />Invoice #: <br />Me- <br />cl0!;ztt <br />