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Date run 10/31/2018 3:42:46F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/31/2018 <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 : ,I <br /> Owner Name JOHN T PETERSEN o V p W d <br /> Owner DBA JOHN T PETERSEN <br /> OwnerAddress 3838 KINGDON RDS �(� �� ' <br /> LODI, CA 95242 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 3838 KINGDON RDS ��'��(� 14-\1' WL(a '`(-1 d1 <br /> LODI, CA 95242 1 A <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017443 10186457 <br /> Facility Name JOHN T PETERSENn Hnc �1 CX U„(Yl <br /> Location 3838 KINGDON RD <br /> LODI, CA 95242 i--OCA(,\ CPr 5243- <br /> Phone 209-333-1865 x0 (- pq) i-;Uq — !13 1:N <br /> Mailing Address 3838 KINGDON RDS t(1 CaOCl �C� <br /> LODI, CA 95242 LOA-1 cft qs- <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 05525020 Email: n�( (dr�CSU . C�fn <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 PETERSEN (Circle One) <br /> Account Balance as of 10/31/2018: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? <br /> � Delete <br /> 1958-HM-Farm Operations PR0525628 EE0002670-MUNIAPPA NAIDU Inactive Y N ( A/�I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0532460 Inactive Y N 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 by QQ�� <br /> EHD Staff: C/ _ LII'1G1�C1 l i Date / / Account out: 4b Date_I / -3d <br /> "" <br /> COMMENTS: Invoice#: ?✓' 1-74-79 <br /> �IeIc1 Olt Coot WX CW tf \MICA OMS . <br />