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Date run 12/20/2016 1:22:03P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 12/20/2016 <br />Record Selection Criteria: Facility ID FA0010717 <br />OWNER FILE INFORMATION Number of facilities for this owner: 6 <br />Owner ID <br />OW0007474 Case Number: H04385 <br />Owner Name <br />CITY OF LODI <br />Owner DBA <br />Owner Address <br />1331 S HAM LN <br />LODI, CA 95242 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-333-6740 <br />Mailing Address <br />1331 S HAM LN <br />LODI, CA 95242 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0010717 10183775 <br />Facility Name 601A t 0r FER nig i <br />Location 2101 W TURNER RD <br />LODI, CA 95242 <br />Phone 209--33-3-67 x0 <br />Mailing Address 1331 S HAM LN <br />LODI, CA 95242-399 <br />Care of <br />Location Code 02 - LODI <br />BOS District 004 - WINN, CHARLES <br />APN 01523013 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />r1lil- WEIR 7 <br />Alt Phone <br />Fax <br />EMail : <br />Account ID AR0017717 <br />Mail Invoices to Owner Mail Invoices to <br />Account Name CITY OF LODI <br />Account Balance as of 12/20/2016: $0.00 <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/ nactve <br />Program/Element and Descdption Record ID Employee ID and Name Status New Owner? Delete <br />1926 - HMBP-Remote Network Location PR0513005 EE0008709 - JAMIE LIMA Active Y N A I D <br />2840 -AST EXEMPT FAC < 1,320 GAL PR0528453 EE0009488 - JEFFREY WONG Inactive 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: <br />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 Received / <br />EHD Staff: Llhni�.� Date �/7D/ 1 0 Account out: t:: Date <br />COMMENTS: <br />Ir1V01Ce #: <br />