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Datemn 3/8/2017 8:59:14AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/8/2017 <br /> Record Selection Criteria: Facility ID FA0010501 <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: 1 SSN/Fed Tax ID <br /> Owner ID OW0008501 Case Number: H08233 New OwnerlD <br /> Owner Name MARTY LANE <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-745-6615 <br /> Mailing Address 13641 JOHN GLENN RD STE C <br /> APPLE VALLEY, CA 923085732 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0010501 <br /> Facility Name LANE CONCEPTS INC <br /> Location 2004 PICCOLI RD 2 <br /> STOCKTON, CA 95215 <br /> Phone 209-464-2792 <br /> Mailing Address 13641 JOHN GLENN RD STE C <br /> APPLE VALLEY, CA 923085732 <br /> Care of MARTY LANE <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 101-180-04 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name MARTY LANE <br /> Title <br /> Day Phone 209-464-2792 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017501 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> ount Name LANE CONCEPTS INC (Clyde Ori <br /> Account Balance as of 3/8/2017: $0.00 <br /> (circle one) <br /> Transfer to Active/InacNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owni Delete <br /> 2220-SM HW GEN<5 TONS/YR PRO541163 EE0000031 -ELIANNA FLORIDO Inactive Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO512789 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO510501 EEOO00000-HAZ MAT SJC DES Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acie,amedgethat all site,andor protect specific,PHS rly charges associated with thisfacility <br /> or activity will be billed to the party identified as the OWNER on this farm. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> 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 <br /> COMMENTS: <br /> Invoice#: <br /> I}; SD�✓l - this is n <br /> kilo/7 4owhaa' Z ei✓aaled you earl;2r'. <br /> Tt�t�s slime r,, s � a�cottr+ hd P,t hce ; s o u rtd <br /> y}a'l'tAS is in4cl-iJ'e— . Y,'m <br />