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Revert»sozl <br /> Date run 3/221E0'17 8:32:17Ary SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Pagel <br /> Ren by ` Facility Information as of 3/22/2017 <br /> Recom Selection Criteria: Facility ID FA0009569 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this ownerz SSN/Fed Tax ID : <br /> Owner ID OW0007124 Case Number: H New Owner ID <br /> t <br /> Owner Name lt�.n�D /tny :SQL. <br /> �[-1 <br /> Owner DBA t Dtt rM7t,v-i <br /> Owner Address dz I <br /> LA A <br /> ncli UFl, gG12"10 <br /> Home Phone .N9E-S¢6Cifia�t <br /> Work/Business Phone §3O R21 "Z4Z — — � \v <br /> Mailing Address <br /> lcldi 0A A52L10 <br /> Careof (',F1NFKF I AR_Y ,11 Y11'%\4a_ C'.0yY1 Mn SC. <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID/CERS ID FA0009569 <br /> Facility Name= <br /> Location 248 E KETTLEMAN LN <br /> LODI, CA 95240 <br /> Phone 204-3--34 ^- °oma— <br /> Mailing Address_P_Ci_ -}248 <br /> t i 0A 52L10 <br /> Care of <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 057-160-10 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016569 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name T4c«'=`a`w�ly (Circle one) <br /> Account Balance as of 3/22/2017: $0.00 <br /> (Cinle One) <br /> Transferto Active'naeve <br /> Program/Element and Description Record ID Employee In and Name ///0 "" Status New Ovmer7 Delete <br /> 1921 -HMBP-Regular-Primary Location PRO519732 EE0008709-JAMIE LIMA� �yrv) Inactive YN (rte( I D <br /> 2220-SM HW GEN<5 TONS/YR PR0513907 EE0000030-AARON HAN Inactive Y N to) I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511857 EE0000000-HAZ MAT SJC OES Inactive Y N X I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0501751 EE9999998-ONE VACANT? Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PRO509569 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATIVE PR0515595 EE0000030-AARON HANG Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO533162 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,amitor project specific,PHS/EHD hourly charges associated with this tacitly or f <br /> be billed to the party,dentRetl as the OWNER on this form. I also minify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor 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 Received by <br /> EHD Staff: Date / / Account out: Date �✓ / ? / 7 <br /> COMMENTS: �� -7 <br /> Invoice#: �9 & <br />