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ERKord <br /> 7/26/2016 3:14:19Pk SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Report#5021 <br /> Facility Information as of 7/26/2016 Pagel <br /> ction Catena: 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 Owner ID <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 B <br /> APPLE VALLEY, CA 923085732 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/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 B <br /> APPLE VALLEY, CA 923085732 <br /> Care of MARTYLANE <br /> Location Code Alt Phone <br /> BOIS District Fax <br /> APN 101-180-04 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 AR0017501 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name LANE CONCEPTS INC (Circle One) <br /> Account Balance as of 7/26/2016: $0.00 <br /> (Circle One) <br /> Transferto Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Omer? Delete <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO512789 EE0000o00-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0510501 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSEHD 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 andfor Standards and State anwor <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 />