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Date mn 3/29/2018 10:00:59AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 3/29/2018 <br />Record Selection Criteria: Facility ID FA0013902 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />owner ID OW0010994 <br />Owner Name HERNANDEZ, GILBERTO <br />Owner DBA HERNANDEZ APPLIANCE <br />Owner Address <br />Home Phone 209-367-1397 <br />Work/Business Phone Not Specified <br />Mailing Address <br />Care of GILBERTO HERNANDEZ <br />FACILITY FILE INFORMATION <br />Facility lD/CERS ID <br />FA0013902 <br />Facility Name <br />HERNANDEZAPPLIANCE <br />Location <br />1340 S HUTCHINS ST <br />LODI, CA 95240 <br />Phone <br />209-367-1397 <br />Mailing Address <br />1340 S HUTCHINS ST <br />LODI, CA 95240 <br />Care of <br />GILBERTO HERNANDEZ <br />Location Code <br />02 - LODI <br />BOS District <br />004 - WINN, CHARLES <br />APN <br />04513038 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />GILBERTO HERNANDEZ <br />Title <br />Day Phone <br />209-367-1397 <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Make changestcorrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID <br />Alt Phone <br />Fax <br />EMail : <br />Account ID AR0023440 <br />Mail Invoices to Facility Mail Invoices to: <br />Account Name HERNANDEZ APPLIANCE <br />Account Balance as of 3/29/2018: $0.00 <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to AMlvellnacive <br />Program/Element and Description Record ID Employee ID and Name S e Owner! Delete <br />2217 -APPLIANCE RECYCLER PR0518429 EE0000030-AARON HANG Inactive Y A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andror project sp HSIEHD hourly charge ociated 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 Orin 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: n Date <br />COMMENTS: p` C7// <br />Date <br />" $25.00 = Amount Paid Date <br />Amount Paid Date <br />Received by <br />Account out: Date ! / <br />Invoice f:: <br />