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Date run 5/1912017 7:57:30AN SAN JOAQUIN COUN'T'Y ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility information as of 5/19/2017 <br /> Record Selection Criteria: Facility fD FA0012731 <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 I Fed Tax ID <br /> Owner ID {3W0009917 New Owner ID <br /> Owner Name Mike Brandt <br /> Owner DBA SAN JOAQUIN CHROME <br /> Owner Address 1709 W ROSE ST <br /> LODI, CA 95240 <br /> Home Phone 209-463-7540 <br /> Work/Business Phone 209-365-9694 <br /> Mailing Address 910 Black Diamond Wy unit B <br /> Lodi, CA 95240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0012731 10451968 <br /> Facility Name San Joaquin Chrome <br /> Location 910 BLACK DIAMOND WAY UNIT B <br /> Lodi, CA 95240 <br /> Phone 209-365-9694 x <br /> Mailing Address 910 Black Diamond unit B <br /> Lodi, CA 95240 <br /> Care of Mike Brandt <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN El <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0021249 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility I Account <br /> Account Name Mike Brandt (Circle one) <br /> Account Balance as of 511912017: $0.00 <br /> (Circle One) <br /> PrograrnlElement and Description Record ID Employee ID and Name Transfer r Actfvelete e <br /> Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PRO520953 EE0008709-JAMIE LIMA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATfON PR0517547 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2247-RCRA GEN 5<25 TONS PR0516668 EE9999998-ONE VACANT1 Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO516670 EE0007289-ALISON YOUNGBLOOD Inactive Y N A I D <br /> LEHD <br /> -ELECTRONIC REPORTING STATE SURCHARG PR0533695 Inactivt Y N A I D <br /> and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ancilor project specific,PHS!€Ho hourly charges associated with this facility <br /> will be billed to the party identified as the OWNER on this farm- also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or <br /> Laws. <br /> CANTS SIGNATURE: Date I 1 <br /> m Records to be TRANSFERED: '$25.00= Amount Paid Date 1 1 <br /> System to be TRANSFERED Amount Paid Date 1 1 <br /> nt Type Check Number Received b <br /> taff: �. Date _l l Account out: Date l�_ IL <br /> NTS <br /> ��� � Invoice#: <br />