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Date run 9/2/2016 3:34:17PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report*5021 <br /> Run by <br /> Facility Information as of 9/212016 Pagel <br /> Record Selection Criteria', Facility ID FA0023625 <br /> Make changeslcorrections in RED ink. O2- � <br /> INFORMATION CHANGE (date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 SSN/Fed Tax ID <br /> Owner ID OW0021929 New Owner ID <br /> Owner Name Ulta Beauty <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 630-410-4110 <br /> Mailing Address 1000 Remington Boulevard, Suite 120 <br /> Bolingbrook, IL 60440 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0023625 10705807 <br /> Facility Name ULTA BEAUTY#1152 (Lodi) <br /> Location 1423 South Lower Sacramento Road <br /> Lodi, CA 95242 <br /> Phone 630-410-4110 x <br /> Mailing Address 1423 South Lower Sacramento Road <br /> Lodi, CA 95242 <br /> Care of Ulta Beauty <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0043667 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner 1 Facility ! Account <br /> Account Name Nedra Allen (Circle One) <br /> Account Baiance as of 9/2/2016: $0.00 <br /> (Circle one) <br /> Transfer to Active!{nactve <br /> ProgramfElement and Description Record 10 Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN{5 TONS/YR PR0541240 EE0001422-ARIS VELOSO Active Y N A I D <br /> BUING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site.and/or project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes ancVor Standards and State and+or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date ! 1 <br /> Program Records to be TRANSFERED '$25.00= Amount Paid Date i I <br /> Water System to be TRANSFERED: Amount Paid Date 1 I <br /> Payment Type Check Number Received by <br /> EHD Staff: Date I 1 Account out: > Date 1 T I _ <br /> COMMENTS: <br /> -POD G '/zy K <br />