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Date run 5/18/2016 4:01:08PIV SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 5/18/2016 Record Selection Criteria: Facility ID FA0010132 OWNER FILE INFORMATION Number of facilities for this owner Owner ID OW0008132 Case Number: H067HO Owner Name KENNETH GREGG Owner DBA GREGG PROPERTY SERVICE OwnerAddress 401 N CALIFORNIA ST LODI, CA 952401046 Home Phone 209-974-5555 Work/Business Phone 209-334-4227 Mailing Address 401 N CALIFORNIA ST LODI, CA 95240-1046 Care of FACILITY FILE INFORMATION Facility ID / CERS ID FA0010132 10183245 Facility Name GREGG PROPERTY SVC Location 401 N CALIFORNIA ST LODI, CA 95240-1020 Phone 209-334-4227 x Mailing Address 401 N CALIFORNIA ST LODI, CA 95240-1046 Care of Kenneth Gregg Location Code 02 - LODI Bos District 004 - WINN, CHARLES APN 03712014 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : _ Alt Phone Fax EMail : Account ID AR0017132 New Account ID: : Mail Invoices to Account Mail Invoices to: Owner / Facility / Account Account Name GREGG PROPERTY SVC (Circle One) Account Balance as of 5/18/2016: $0.00 (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1921 - HMBP-Regular-Primary Location PR0520125 EE0008709 - JAMIE DE LA ROSA Active Y N AD 2220 - SM HW GEN <5 TONS/YR PR0514187 EE0001422 - ARIS VELOSO Active Y N A I D 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512420 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0510132 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARGE PR0531844 Inactive Y N A I D 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 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 ancvor Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: * $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Tye Check Number Receiveclhoq EHD Staff: . Date / / Account out: Date-:f= COMMENTS: Yvr— Invoice #: