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Date run 1/30/2017 3:14:55PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 1/30/2017 Pagel <br /> Record Selection Criteria: Facility ID FA0017951 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0014747 New Owner ID <br /> Owner Name LOUIE J SOARES <br /> Owner DBA Qe S us Y11- <br /> Owner Address 400 N CLU FF AVE <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-334-0617 <br /> Mailing Address 400 N CLUFF AVE#A <br /> LODI, CA 95240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017951 10186721 <br /> Facility Name cam+ nC , <br /> Location 400 N CLUFFAVE#A <br /> LODI, CA 95240 <br /> Phone 209-334-0617 x <br /> Mailing Address 400 N CLUFF AVE#A <br /> LODI, CA 95240 <br /> Care of Gene Takeuchi <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 04934014 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 AR0031484 NewAccount ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name OLYMPIC TUNE/STREET RODS PLUS (Circle One) <br /> Account Balance as of 1/30/2017: $615.00 <br /> (Circle One) <br /> Transfer to Aciivellnache <br /> Program/Element and Description Record ID Employee ID and Name Status New OwneR Delete <br /> 1921 -HMBP-Reqular-Primary Location PR0526510 EE0008709-JAMIE LIMA Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0526848 EE0000006-HAZA SAEED Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE PR0533795 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 specFic.PHSEHD hourly charges associated with this facility <br /> or activity,will be billed to the party identfied as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes ender Standards and State an ifor <br /> Federal Laws. <br /> APPLICANT'S 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 y <br /> EHD Staff: .l�t�(A.-. Date�L/1�/ Account out: Date �1 -4-- <br /> COMMENTS <br /> COMMENTS: <br /> Invoice#: <br /> 1VK�ftss yam"/"►yam <br /> V w f%W <br />