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Date run 3/22/2.017 8:32:17Ary SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Repon95021 <br /> Run by Pager <br /> Facility Information as of 3/22/2017 <br /> Record Selection Criteria: Facility ID FA0009569 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for thisowne2 SSN/Fed Tax ID : <br /> Owner ID OW0007124 Case Number: H New Owner ID <br /> Owner Name �(JNV11-e. ra mm i S 0.- <br /> Owner DBA <br /> Owner Address-n;" 0Nl jCl G-p <br /> Edi , 61tp. C1924O <br /> Home Phone Nst-� y <br /> Work/Business Phone.&a0 R21 4747 <br /> Mailing Address 'L 6 <br /> l odi lGW g52ND <br /> Careof rFNFKF I4RRy 1111nNt4?- C4rylm�Scie� <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID/CERS ID FA0009569 <br /> Facility Name GFtA/F14E fiV <br /> Location 248 E KETTLEMAN LN 1 1 i <br /> LODI, CA 95240 <br /> Phone.209-334-9987. <br /> Mailing AddresswP�OL94@p� <br /> 6991, GA tt-()C11 ISM 457LAD <br /> Care of <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 057-160-10 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016569 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name (Circle One) <br /> Account Balance as of 3/22/2017: $0.00 <br /> (Circle One) <br /> ProgramlElement and Description Record lD Em ae lD end Name Transfer to Actiiylragve <br /> p oY ////'''' status New Owner? Delete <br /> 1921-HMBP-Regular-Primary Location PRO619732 EE0008709-JAMIE LIMA f g t/&4ine,) Inactive Y N (D I D <br /> 2220-SM HW GEN<5 TONSNR PR0513907 EE0000030-AARON HAN Inactive Y NAV l ID <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511857 EE0000000-HAZ MAT SJC OES Inactive Y N ��� I D <br /> 2381-UST FACILITY(BEFORE 1/84)-obsolete PRO501751 EE9999998-ONE VACANTI Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PRO509569 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATIVE PRO515595 EE0000030-AARON HANG Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0533162 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specinc.PHSfEHD hourly charges associated wM this facility or[ <br /> N billed to the party dentrad as the OWNER on this form. I also certify,that all operations will be performed in accordance with all applicable Ordinance Codes endo,Standards and State ander Federal Laws. <br /> APPLICANTS 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 /> EHD Staff: Date_/ / Account out: el� Date / I 7 <br /> COMMENTS: �Q/-W7 <br /> Invoice#: 7 ` <br />