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Date run 8/22/2017 10:26:35AI SAN JQ UIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/22/20'IT <br /> Record Selection Criteria: Facility ID FA0021232 <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 OW0017502 New Owner ID <br /> Owner Name RATTANASACK, SOUK <br /> Owner DBA TOBACCO CITY <br /> OwnerAddress 1739 GENOA DR <br /> MANTECA, CA 95336 <br /> Home Phone 209-333-1631 <br /> Work/Business Phone 209-329-2146 <br /> Mailing Address 550 S CHEROKEE LN STE G <br /> LODI, CA 95240 <br /> Care of RATTANASACK, SOUK <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0021232 <br /> Facility Name TOBACCO CITY (SOUK RATTANASACK) <br /> Location 550 S CHEROKEE LN STE G <br /> LODI, CA 95240 <br /> Phone 209-333-1631 <br /> Mailing Address 550 S CHEROKEE LN STE G <br /> LODI, CA 95240 <br /> Care of RATTANASACK, SOUK <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 04745018 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SOUK RATTANASACK <br /> Title <br /> Day Phone 209-333-1631 <br /> Night Phone 209-329-2146 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0038345 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name TOBACCO CITY UK RATTANASACK) (Circle One) <br /> Account Balance as of 8/22/2017: $212.0 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4110-BODY ART PRACTITIONER REGISTRATION PR0536980 EE0003973-ROBERT MCCLELLON Inactive Y N A J_, D <br /> 4120-BODYART FACILITY-SINGLE USE PR0536979 EE0003973-ROBERT MCCLELLON Active Y N A Q 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 N ber Received b <br /> EHD Staff: /l ( Date l Z l Account out: Date <br /> COMMENTS: �. Invoice#: <br /> l <br />