Laserfiche WebLink
Report W21 <br /> Dateran . 5/9/20`17 12:02:11PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Pagel <br /> Run by Facility Information as of 5/9/2017 <br /> Record Selection Criteria: Facility ID FA0013644 <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 OW0010757w ow er ID <br /> Owner Name *HA4-8AFnAR" i ' raV 7) <br /> Owner DBA <br /> Owner Address =t-)L G t e O 1iv.n.n <br /> LODI, CA 95240 �n <br /> Home Phone-2.Q9.327-469Q.—M7�'"t y1 113z,to <br /> Work/Business Phone <br /> Mailing Address <br /> LODI, CA 95240 <br /> Care of -KHAN-,SUIFDATT� <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0013644 10184485 <br /> Facility Name <br /> �� <br /> Location 720 E LODI AVE <br /> LODI, CA 95240 <br /> Phone Qeq:*e�`s� — <br /> Mailing Address 720 E LODI AVE <br /> LODI, CA 95240 <br /> Care of X+hV4-, SAf-BA1r^ <br /> Location Code 02- LODI Alt Phone <br /> SOS District 004 -WINN, CHARLES Fax <br /> APN 04745013 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 AR0022800 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name p 'I, Itz D &I (Circle One) <br /> Account Balance as of 5/9/20 ' : $487.0 —� A � <br /> (Circe One) <br /> Transferto Acbye4nactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner! Delete <br /> 1921 -HMBP-Regular-Primary Location PR0521048 EE0008709-JAMIE LIMA Inactive Y N ® I D <br /> 2220-SM HW GEN<5 TONS/YR PR0517990 EE9999998-ONE VACANTI Active Y N A 1 D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0517991 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0517992 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532277 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSyEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also candy that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or <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 T�Check Number Receivedy _ <br /> EHD Staff: �I 4- Date / / Account out: Date 277 o / /7 <br /> COMMENTS: <br /> Invoice#: <br /> lUb b�s� r>css l i e�t�� V' <br />