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Date run 10/25/2016 8:27:38A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10125/2016 <br /> Record Selection Criteria: Fediity ID FA0013539 <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 OW0010665N1ew"�Owner ID <br /> Owner Name [—COJtarrcl E-�a..yr� ,v� <br /> Owner DBA <br /> OwnerAddress 1255 S BECKMAN <br /> LODI, CA 95240 <br /> Home Phone ^off2_7fffybll57 <br /> Work/Business Phone 209-263-3999 <br /> Mailing Address 1255 S Beckman Rd <br /> Lodi, CA 95240 <br /> Care of LODI CHRYSLER, DODGE, JEEP, RAM LP <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0013539 10477726 <br /> Facility Name Lodi Chrysler Dodge Jeep Ram <br /> Location 1255 S Beckman Rd <br /> Lodi, CA 95240 <br /> Phone 209-263-3999 x <br /> Mailing Address 1255 S Beckman Rd <br /> Lodi, CA 95240 <br /> Care of <br /> Location Code Alt Phone C <br /> BOS District 004-WINN, CHARLES Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION wwnn <br /> Contact Name <br /> Title FIXED OPS MANAGER <br /> Day Phone 209-263-3999 <br /> Night Phone y 08 —TC10—OZ9dt <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account lD AR0022643 New AccountlD: : <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Renee Carey (Circle One) <br /> Account Balance as of 10/25/2016: $0.00 <br /> (Circle One) <br /> Transfer to ActlWnactve <br /> Program/Element and Description Record ID Employee 10 and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PR0521092 EE0008709-JAMIE LIMA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO517655 EE0000o00-HAZ MAT SJC OES Inactive Y N A I D <br /> 2227-GEN 5<25 TONS PERMIT PR0518755 EE0000005-FATINAH ZAREEF Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0517656 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATIVE PR0518759 EE0000005-FATINAH ZAREEF Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0523246 EE0009000-HARPRIT MATTU Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO534124 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,ander project specific,PHVEHD hourly charges associated with this facility <br /> or activity will be billed to Ne party identified as Me OWNER on this form. I also certify that sit operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State ander <br /> Federal Lewis <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 b <br /> EHD Staff: Date Account out: Date <br /> COMMENTS: Invoice#: <br /> 't�al�`Y7N "^� Oe� vvirl-tvSl'(r�P <br />