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11:Lt_j 111y4640138 <br /> ENVIRONMENTAL 'HEALTH PAGE 02IO2 <br /> Dale n 91181;00$ 841:42AA _..� ���N <br /> Runbv SAN 3t _ UIN COUNTY EKK OO ENTAL 1TTEA H>0EIPARTMEIVT Report d5a�r <br /> Facility information as Of 9/1 812 0 0 8 <br /> Reeard 5[afec7lon Crijerra; Focltlry fD <br /> FA000275$ <br /> Make changestcOrmutions fn RED ink or pencil <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(dale) <br /> Owner ID OW0000031 SSN I Fed Tax 10 ; <br /> Owner Name LODI UNIFIED SCHOOL DIST New Owner ID <br /> Owner D9A LODI UNIFIED SCHOOL DIST <br /> Owner Address 1305 ✓* VINE ST <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-331_7000 <br /> Mailing Address 1305 E VINE ST <br /> LODI, CA 95240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0002753 <br /> Facility Name LODI USD-MORADA MIDDLE SCHOOL <br /> Location 5001 EASTVIEW DR <br /> STOCKTON, CA 95212 <br /> Phone <br /> Mailing Address 1306 E VINE <br /> LODI, CA 95240 <br /> Care of LODI UNIFIED SCHOOL DISTRICT <br /> Location Code 99 - UNINCORPORATED ra Alt Phone <br /> 80S District 004-VOGEL, KEN Fax ` <br /> APN 08607043 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 AR0004513 New Account D. <br /> Mail Invoices to Owner Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name LODI UNIFIED SCHOOL DIST (C*areOne} <br /> Account Balance as of 9 11 812 0 0 8: $0.00 <br /> (Clrcfe One) <br /> Pro remlElem tandDescrl loan 3tedjs Tranaterto AetNWInacive <br /> 9 p Record ID Emproyee ID and NAMrr New Cvmen 091018 <br /> 1632-EXEMPT FOOD PRO160899 EE0006213-VIDAL PEDRAZA Active Y N A I D <br /> 3116-STORMWATER INSPECTION-FOOD PR0522892 EE0006213-VIDAL PEDRAZA Inactive Y N A I D <br /> 4630-NTNC WATER SYSTEM WA0461109 EED005838-ADRIENNE ELLSAESSEACtive Y N A I D <br /> BILLING end COMPLIANCE ACKNOWLEDGEMENT; f,the underalAned owner,operator or agent of same.ncknawledga Ihe1 All site,and/or pmjoc(speclllc.PHS17EHD hourly merges 1rtMIRted wnh this <br /> radllty or eativlty will ba billed to M0 party Idenim%d ns the OWNER on tide form. I also corny that all weratlon An be perronnod fn ac comence with oil oppllmbfe 001nuco Codas And for Standards?nd <br /> State and/or Fo4eral Law*-. <br /> APPLICANT'S SIONATURE: _. , ti, _ Date _1! 211 / 08 <br /> Program Records to be TRANSFERED: $20,00= Amount Paid Date ! <br /> Wster System to be TRANSFEREp; '$372.00= Amount Pnid Datn I I <br /> Payment Type Check Number Received b <br /> REHS_ Date / J Account out; Date <br /> COMMENTS: �} --�— — -- <br /> f�—�,�. <br /> 1Nphs-ehsol-ntlapps%envisionstrepors) rp <br />