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BILLING_PRE 2019
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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LOCKEFORD
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2200 - Hazardous Waste Program
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PR0542783
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BILLING_PRE 2019
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Entry Properties
Last modified
3/15/2021 10:24:18 PM
Creation date
11/1/2018 11:30:03 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2200 - Hazardous Waste Program
File Section
BILLING_PRE 2019
FileName_PostFix
PRE 2019
RECORD_ID
PR0542783
PE
2221
FACILITY_ID
FA0024563
FACILITY_NAME
Grayson Engineering (Lodi CA )
STREET_NUMBER
1045
Direction
E
STREET_NAME
LOCKEFORD
STREET_TYPE
ST
City
LODI
Zip
95240
APN
049-030-022
CURRENT_STATUS
01
SITE_LOCATION
1045 E LOCKEFORD ST
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\L\LOCKEFORD\1045\PR0542783\BILLING.PDF
QuestysFileName
BILLING
QuestysRecordDate
4/16/2018 6:10:19 PM
QuestysRecordID
3855356
QuestysRecordType
12
QuestysStateID
1
Tags
EHD - Public
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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> MASTERFILE RECORD INFORMATION FORM <br /> SHADED SECTIONS FOR EHD USE ONLY OWNER ID# o&)oo a3/SI CASE# <br /> OWNER FILE <br /> COMPLETE THE FOLLOw/NG BUSINESS OWNER INFORMA nom CHEcKIF OWNER CURRENTLYONFiLEwtTHEHD❑ <br /> BUSINESS PHONE: <br /> OWNER'S NAME <br /> Flat Miji Last <br /> BUSINESS NAME(If different from Owner Name) SOC Sec orTax ID# <br /> OWNER'S HOME ADDRESS <br /> CIN STATE zip <br /> O NER'S MAILING ADDRESS (If different from Owner's Address) Attention orCare of <br /> Lo Z <br /> MAILING ADDRESS CIN I /��1 zip / 1 <br /> TYPE OF OWNERSHIP: <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ LOCAL AGENCY❑ COUNTY AGENCY❑ STATE AGENCY❑ FED AGENCY OTHER❑ <br /> FACILITY FILE <br /> FACILITYID#: C) ,LLf j CO-OWNER ID#: ACCOUNTID#: <br /> COMPLETFTHEFOLLOwlwBUSINESS FACILITY INFORMAT/ON: <br /> F',- <br /> hla a NEW Business LOCATION or VEHICLE not previously regulated by the ENVIRONMENTAL HEALTH YES NO ❑ <br /> nahl_u his an E%ISTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No ❑ <br /> BusiNr4FACILITY NAME(This will be the BuswEss NAmEon the HEALTH PERMIT) <br /> Q <br /> FAC 10 <br /> ADDR (If FAC/Llrris a Mosl EFooD UNtror FooH/CLEea the COMMISSARY ADDRESS) BUSINESS PHONE ' I <br /> 4 U 1l � <br /> 5 - � Suite# t/ <br /> CI (IfFACl/ITVIS a MOSILEF000 UNITOr FOOD VEHICLE use the COMMISSARY CIM STATE zip ' 1 <br /> CAq 52 �(9 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING DDRES fOFHealth Permit(If OIFFERENTfrom FacilityAddmss) Attention orCare Of <br /> MAILING ADDRESS CITYLLI STATE zip LA <br /> SIC CODE: APN#: COMMENT: �-{ <br /> ACCOUNTADDRESS for fees and charges: OWNER ❑ FACILITY/BUSINESS ❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner, Operator,or Authorized Agent of this Business,and <br /> 1 acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the <br /> address identified above as the ACCOUNTAODREss for this site. I also certify that all information provided on this application is true and correct;and that <br /> all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or <br /> FEDERAL Laws and Regulations. <br /> APPLICANT'S NAME: SIGNATURE: <br /> Please Print <br /> TITLE: DATE DRIVER'S LICENSE# <br /> PHOTOCOPY REQUIRED <br /> Approved By Date Accounting Office Proceeeing Completed By � /j, Dam <br /> A PROGRAM{EHD 48-02-034 Pink}or WATER SYSTEM{EHD 46-02-003}form must be completed for each EHD regulated operation at this LOCATION <br /> except UST Program(Use SWRCB forms) <br /> EHD 48-02-035 Masterfile Record-Green <br /> 8/19/08 <br />
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