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t <br /> Date run 6/3/2020 10:12:52AM SAN JO IN COUNTY ENVIRONMENTAL HEAL 4EPARTMENT Report#5021 <br /> Run by„ % Pagel <br /> Facility Information as of 6/3/2020 <br /> Record Selection Criteria: Facility ID FA0000454 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/ d Tax ID <br /> Owner ID OW0000373 New Owner <br /> Owner Name <br /> Owner DBA <br /> Owner Address 2488 GENT-RikE-PAfRi� <br /> 5 0 <br /> Work/Business Phone Not Specified <br /> Alternative Phone-209-986-5341- <br /> Mailing <br /> - -Mailing Address • <br /> 2 SZy / <br /> Care of CANTON, ANTI-IO1NY <br /> FACILITY FILE INFORMATION 1.0C ,e YSa. 31— <br /> Facility ID/CERS ID FA0000454 • , _ <br /> Facility Name - <br /> Location 13631 N HURD RD SO4 / <br /> LODI, CA 95240 <br /> Phone 209-986-5341 <br /> Mailing Address 2486 GENTRA i PARK R <br /> L 7 <br /> Care of C <br /> Location Code 99 - UNINCORPORATED A Alt Phone �6 - 3 0 <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 06104007 EMail: <br /> -- O <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION J <br /> Contact Name C Y � CA <br /> Title Q f, y- <br /> Day Phone <br /> Night Phone I.:1 CZ— Cp — J 2 Z <br /> ACCOUNTS RECEIVABLE FILE INFORMATION UU\\11 JUN LLO�� 202 I <br /> Account ID AR0000453 New Account ID: <br /> Mail Invoices to Owner 'ENVIRON NTAL LTH Mail Invoices to: Owner / Facility / Account <br /> Account Name Y PE /SERVICE (Circle One) <br /> Account Balance as of 6/3/2020: $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 /> 2765-EMPLOYEE HOUSING-PERMANENT>180 DAYS PR0270120 EE0009819-MARYANN BENIAMINE Active N A I D <br /> 4617-EMPLOYEE HOUSING-WATER SUPPLY WA0515730 EE0008987-SCOTT SANGALANG ActiveY-_ TI 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 co 99d==its lT is 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 ,�/F�( and/or <br /> Federal Laws. <br /> JUN 0 3 2020 <br /> APPLICANT'S SIGNATURE: Date l I-SANJOA1,p . <br /> n 4:N111COU <br /> Program Records to be TRANSFERED: �*$25.00=�L Amount Paid �.S Date / H� N'W RAIIN N <br /> Water System to be TRANSFERED: Amount Paid Date l l P�TMENT <br /> Payment Ty�> �� Check Number ReceivjZeDate2_0 <br /> EHD Staff Date / / OAccount out: <br /> COMMENTS: Invoice#:_337(a12- <br /> v <br />