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Date run 2/25/2016 1:07:44PA SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 2/25/2016 Record Selection Criteria: Facility ID FA0014064 OWNER FILE INFORMATION Number of facilities for this owner Owner ID OW0011135 Owner Name NIES, MARVIN L Owner DBA Owner Address 9296 E KETTLEMAN LN Active/Inactve LODI, CA 95240 Home Phone Not Specified Work/Business Phone Not Specified Mailing Address 92 jV KECTTI CSA A AI LN Active L 0 Care of NIES, MARVIN L FACILITY FILE INFORMATION Facility ID / CERS ID FA0014064 10184555 Facility Name NIES, MARVIN L 39-397 Location 9296 E KETTLEMAN LN LODI, CA 95240 Phone 209-481-8588 Mailing Address N L ND nti nc Care of NIES, MARVIN L Location Code 99 - UNINCORPORATED P Bos District 004 - WINN, CHARLES APN 06315059 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0023792 Mail Invoices to Facility Account Name NIES, MARVIN L 39-397 Account Balance as of 2/25/2016: $53.00 Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN/Fed Tax ID New Owner ID : L S o -3 30 Alt Phone Fax EMail : Mail Invoices to: New Account ID: : Owner / Facility / Account (Circle One) Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number EHD Staff: COMMENTS: $25.00 = Date Amount Paid Date _/_/ _ Amount Paid Date Received by Account out: 24&� Date Z Invoice #: ,A-Ac.,:,l�N �j- A o�CN�tSS Gsic.,+ S� ct s P GT rc" �vrtJ 1MA,� - (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1958 - HM -Farm Operations PR0525951 EE0002670 - MUNIAPPA NAIDU Active Y N A I D 2795 - EMPLOYEE HOUSING -HISTORICAL CAMPS PRO518684 EE0002646 - THUY TRAN Inactive Y N A I D 2840 -AST EXEMPT FAC < 1,320 GAL PR0529492 EE0000753 - WILLY NG Inactive Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARG PRO534241 Inactive Y N 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: Water System to be TRANSFERED: Payment Type Check Number EHD Staff: COMMENTS: $25.00 = Date Amount Paid Date _/_/ _ Amount Paid Date Received by Account out: 24&� Date Z Invoice #: ,A-Ac.,:,l�N �j- A o�CN�tSS Gsic.,+ S� ct s P GT rc" �vrtJ 1MA,� -