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Date run 10/10/2018 12:51:241 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by 1 41 Pagel <br /> Facility Information as of 10/10/2018 <br /> Record Selection Criteria: Facility ID FA0017443 <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 OW0014284 New Owner ID <br /> Owner Name JOHN T PETERSEN <br /> Owner DBA JOHN T PETERSEN <br /> Owner Address 3838 KINGDON RDS <br /> LODI, CA 95242 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 3838 KINGDON RDS <br /> LODI, CA 95242 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017443 10186457 <br /> Facility Name JOHN T PETERSEN <br /> Location 3838 KINGDON RD <br /> LODI, CA 95242 <br /> Phone 209-333-1865 x0 <br /> Mailing Address 3838 KINGDON RDS <br /> LODI, CA 95242 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 05525020 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 AR0030325 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name JOHN T PETER (Circle One) <br /> Account Balance as of 10/10/2018: $1 .00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? <br /> 1958-HM-Farm Operations PR0525628 EE0002670-MUNIAPPA NAIDU Active Y N A� I — <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532460 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,PHS/EHD 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 and/or Standards and State and/or <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 b <br /> EHD Staff: Date / / Account out: Date / / <br /> COMMENTS: <br /> Invoice#: <br />