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[Racmr! <br /> ate nm y812017 1:58:34PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ReRo^ i <br /> un by <br /> Facility Information as of 2/8/2017 Pawl <br /> Seledion Cram: Facility ID FA0015357 <br /> Make changewcorrections in RED ink <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) ., <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN ed Tax ID : <br /> OwnerlD : LAI--00a 4 V <br /> EVE M t <br /> Owner Dor <br /> er` R a <br /> OwnerAddress 5 /y B trk4r R <br /> -t66heA95240-- /,o ate Cif 4 O <br /> Home Phone 2 <br /> Work/Business Phone 209-224-5284 <br /> Mailing Address 533VOT01OW-SfNt{ 7, rommer(A S� 0-16Z, <br /> LODI, CA 95240 <br /> Cale of <br /> FACILITY FILE INFORMATION <br /> Facility ID J CERS ID FA0015357 10184927 r� <br /> Facility Name /7✓',An'S Ct.es4-orv+ Gar5e- <br /> Location 43 COMMERCE ST STE 102 <br /> LODI, CA 95240 <br /> Phone 209-224-5284 <br /> Mailing Address 43 COMMERCE ST#102 <br /> LODI, CA 95240 <br /> Cale of _ ____ _._-_ ... L�reotr% (S,) forea4-h <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax (aacf d,,ZH - S;; 5-5— <br /> APN 04924004 EMad: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact NameS ."Ar M ENT a, f"4/1 G-i 1 ENta;'h <br /> Title OWNER -4EGEIVED <br /> Day Phone 209-224-5284 <br /> Night Phone �gp. .g�-._. �;s 1 0 2017 due) 3.73- -5 le 8 a <br /> ACCOUNTS RECEIVABLE FILE INFORMATION SAN JOAQUIN COUNTY <br /> Account ID AR0026458 ENVIRONMENTAL - New Account ID: <br /> Mail Invoices to Facility HEALTH DEPARTMENT Mail Invoices to: Owner !`�Facility�/ Account <br /> Account Name lMa1 <br /> Account Balance as of 2/8/2017: $261.00 <br /> - lUlefl Ohre) <br /> The ower AdiDelete <br /> Program/Element antl Description RecoM ID Employee 10 and Name Status New Owner! Delete <br /> 2220-SM HW GEN<5 TONSNR PR0522542 EE0000006-HAZA SAEED Active Y N �V 1 D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO533263 Inactive Y N A 1 D <br /> e1LLING arM COMPLIANCEACMOWLEDGEMENT: I,ft untlersigned awnar,operator or agar d same,arhnowl w that all wo.ander project specific.PHSEHD houtly charges assxui wph this lanky <br /> or activity wa be billed bt the party iEenb w Me OWNER on Mh fomt I also eerbp Ihat all openeone will W perPormM in a=mlarw with all applicable Ordinance Cotler andor Stanitaltle and State ar r <br /> Federal Lew s. <br /> APPLICANTS SIGNATURE: r� Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date J / <br /> Water System to be TRANSFERED: Amount Paid ;Lr.1 'a? Date--3 d fo l-L-�- <br /> Payment Type CAlf— Check Number 1Z0 <br /> a Receive <br /> EHD SWR: 412(.4'd& /V1 Date SLI 1 I o /J]_ Account out: Date <br /> COMMENTS: <br /> Invoice# l 1 l <br /> C- f l ' I ( 1 -7 <br /> I <br />