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Date run 3/27/2023 2:57:43PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/27/2023 <br /> Record Selection Criteria: Facility ID FA0026811 <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 : V7 - 1 k 5 L p 7 <br /> Owner ID OW0025463 New Owner ID <br /> Owner Name-$f�0Jt,-"1eHA-E-L <br /> Owner DBA CENTRAL VALLEY LIONS YOUTH FOOTBAI g C ,, I cei 5'^thy ( ( C'-c. L.., e- <br /> Owner Address ?3 0 Cc r f f-)k AV z <br /> Work/Business Phone Not Specified <br /> Alternative Phone _ _ <br /> Mailing Address R T0 C c r lk o -L A d e <br /> S. .5i 6,- kr- cA ��ao -� <br /> Care of-- L Ci e C. <br /> FACILITY FILE INFORMATION APN <br /> Facility ID/CERS ID FA0026811 <br /> Facility Name <br /> Location 221 E LAWRENCE AVE <br /> LODI, CA 95240 <br /> Phone 209-739-0974 E c' S�- > t - >9 u <br /> Mailing Address A5 �' a I- 9v < <br /> Care of c c rLc,cc <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION PAYMENT <br /> Contact Nameef �rt RECEIVED s-, T,,,- <br /> Title <br /> Day Phone _ _ MAR 2 7 2023 o s - I v 2 <br /> Night Phone <br /> SAN JOAQUIN COUNTY <br /> ACCOUNTS RECEIVABLE FILE INFORMATION ENVIRONMENTAL <br /> Account ID AR0051128 HEALTH DEPARTMENT New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name (Circle One) <br /> Email invoice to(up to 2 emails) N L P�i.r <br /> Email permit to(up to 2 emails) `, <br /> Account Balance as of 3/27/2023: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1695-TEMPORARY EVENT PR0547234 EE0009825-DARIAAFONSKAIA Active,l 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: H <br /> /— Date _/ / Z <br /> Program Records to be T NSFERED: *$25.00= Amount Paid Date 3 /71 23 <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received b <br /> EHD Staff: Date_ 'L) / _/ Account out: Date Iq/ Z <br /> COMMENTS: <br /> Invoice#: <br />