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Date win 3/22/?A17 8:32:17Ary SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Pagel <br /> Ran by � Facility Information as of 3/22/2017 <br /> Record Selection Criteria: Facility ID FA0009569 <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 SSN/Fed Tax ID : <br /> Owner ID OW0007124 Case Number: H New Owner ID <br /> Owner Name i/1NVlt?Owner DBA <br /> DBA <br /> Owner Address-^ r nniCT "rT ^^ i , //�fir Ay)61-''1"1 <br /> Un <br /> �J3! (C.`IA, '192"10 <br /> Home Phone eNe-� <br /> Work/Business Phone Q0-u32'I "747 — 3\Qb'_('Q,_Z,=^, \o <br /> Mailing Address 2.�g C 1t4it..Ywt_)t in - <br /> 1 ndi CIA q5 NO <br /> Careof 111` me ULVNlmL sc� <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID/CERS ID FA0009569 <br /> Facility Name GIDArca« R 0 A 1 i.Y�111L1 <br /> Location 248 E KETTLEMAN LN <br /> LODI, CA 95240 <br /> Phone 20&-334l `) _. �'-A, U <br /> ¢ _-'1 <br /> Lk <br /> Mailing Address_P8Q� !Ty I1-}2�9 P . A61a l"1 <br /> Fee riT� chi CM 57ub <br /> Care of <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 057-160-10 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 AR0016569 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name Ttr �ar�VC l`pr.#DAAIV (Circle One) <br /> Account Balance as of 3/22/2017: $0.00 <br /> (Circe One) <br /> Transfer to AcWerneclve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner! Delete <br /> 1921 -HMBP-Regular-Primary Location PRO519732 EE0008709-JAMIE LIMA I(g "" ) Inactive Y N (�( I D <br /> 2220-SM HW GEN<5 TONS/YR PR0513907 EE0000030-AARON HAN Inactive Y N tA) I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO511857 EE0000000-HAZ MAT SJC DES Inactive Y N A' I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PRO501751 EE9999998-ONE VACANT? Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0509569 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATIVE PRO515595 EE0000030-AARON HANG Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO533162 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT'. I,the undersigned owner,operator or agent of same,acknowledge that all site,ander project specifc,PHSEHD hourly charges associated with this faulity or r <br /> he billed to the party identified as the OWNER on this form. 1 also certify that all operations will be performed in accordance with all applicable Ordinance Codes ani Standards and State ani 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 by <br /> EHD Staff: Date / / Account out: Date / ? / 7 <br /> COMMENTS: .21/-74,-7 <br /> 1/-7V/.-7 <br /> Invoice#: l <br />