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r <br /> Date run 11/29/2018 10:29:34A SAN JO. JIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 11/29/2018 <br /> Record Selection Criteria: Facility ID FA0000454 <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 OW0000373 New Owner ID <br /> Owner Name CANTON,ANTHONY <br /> Owner DBA <br /> Owner Address 1 ) <br /> LODI, CA 952400505 L L) C l+ H S'-1 U <br /> Home Phone -299=334--9590- <br /> Work/Business Phone Not Specified <br /> Mailing Address 1231 MIDVALE <br /> LODI, CA 952400505 <br /> Care of CANTON,ANTHONY <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0000454 <br /> Facility Name CANTON LABOR CAMP 39-120 <br /> Location 13631 N HURD RD <br /> LODI, CA 95240 <br /> Phone 209-334-9590 <br /> Mailing Address 1''�(vVA-EC <br /> LODI, CA 9&249859a-- <br /> Care of CANTON,ANTHONY <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 06104007 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name CANTON,ANTHONY <br /> Title <br /> Day Phone-20#--,j34-,959G' <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000453 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name CANTON,ANTHONY (Circle One) <br /> Account Balance as of 11/29/2018: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New OwneO Delete <br /> 2765-EMPLOYEE HOUSING-PERMANENT>180 DAYS PR0270120 EE0006219 Activ Y N A I D <br /> 4617-EMPLOYEE HOUSING-WATER SUPPLY WA0515730 EE0008987-SCOTT SANGALANG dive 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: 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 Re� <br /> EHD Staff: � / Dated / .Z `j / Account out: ` Date <br /> COMMENTS: �� �O�[1 �t�J�� �p � r Invoice#: <br />