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Dale run 6/3/2015 11:42:11AM SAN JO AN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Repon#5021 <br /> Run byPagel <br /> Facility Information as of 6I3I201 <br /> Record Selection Criteria: Facility ID FA0017939 <br /> Make changesicorrections in RED ink. <br /> INFORMAZON CHANGE(date) 1. <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> ownerlD OW0014735 New Owner ID : <br /> Owner Name CHRISTOPHER BECKER <br /> Owner DBA 11NL <br /> Owner Address 334 E LOCKEFORD ST <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-986-4868 -CPZ4- <br /> Mailing Address 334 E LOCKEFORD ST <br /> LODI, CA 95240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017939 10186707 <br /> Facility Name <br /> Location 334 E LOCKEFORD ST <br /> LODI, CA 95240 <br /> Phone 2QQ-334-51'61- XO 7-09 --jam f_59:9,1 <br /> Mailing Address 334 E LOCKEFORD ST <br /> LODI, CA 95240 <br /> Care of <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004-WINN, CHARLES Fax <br /> APN 04309014 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 AR0031472 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name CHRISTOPHER BECKER (ClmaeOne) <br /> Account Balance as of 6/3/2015: $571.00 <br /> (circle one) <br /> Transfer to Activellnadve <br /> Program/Element and Description Record 10 Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO526498 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO538584 EE0001422-ARIS VELOSO Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534324 Inactivr Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned owner,operator or agent ofsame,acknowledge that all site,andor project specifie,PHSIEHD hourly charges associated with this facility or. <br /> be billed to the Party identified as the OWNER on Nis form I also certfly that all operations will be performed!in accordance with all applicable Ordinance Codes ander Standards and State andor Federal Laws. <br /> APPLICANTS 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 / 1A / Account out: Date_/ //5' <br /> - <br /> COMMENTS: <br /> Invoice#: <br />