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Date run 2/26/2016 2:08:27PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 2/26/2016 <br />Record Selection Criteria: Facility ID FA0018378 <br />OWNER FILE INFORMATION Number of facilities for this owner : 1 <br />Owner ID OW0015097 <br />Owner Name Eagle Systems International Inc DBA Synergy <br />Owner DBA <br />OwnerAddress 1376 E TURNER RDA <br />LODI, CA 95240 <br />Home Phone Not Specified <br />Work/Business Phone 800-439-9610 <br />Mailing Address 28436 Satellite St <br />Hayward, CA 94545 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0018378 10588519 <br />Facility Name Synergy Companies <br />Location 1376 E TURNER RD STE A <br />Lodi, CA 95240 <br />Phone 877-836-1329 x <br />Mailing Address 1376 E Turner Rd Ste A <br />Lodi, CA 95240 <br />Care of David Price <br />Location Code <br />BOS District <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION r c/" • 1 <br />Account ID AR0032425 <br />Mail Invoices to Account <br />Account Name David PLP <br />rice l\ I <br />Account Balance as of 2/26/2016: $3 .00 <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 />0011 <br />�I1Lw��U► /o <br />Fax <br />EMail : <br />Mail Invoices to: <br />New Account ID: : <br />Owner / Facility <br />(Circle One) <br />Account <br />(Circle One) <br />91- Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />V-20 - HMBP-Common Materials PR0527119 EE0008709 - JAMIE DE LA ROSA Active Y N A D <br />2220 - SM HW GEN <5 TONS/YR PRO539580 EE0001422 -ARIS VELOSO Active Y N A 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 Typ Check Number Received by <br />EHD Staff: Date / /1� Account out: Date / <br />COMMENTS: <br />n �^ I /91 ��p f � Opw <br />j� _ a Invoice #: <br />(%V(w1V'6 1 lk%� W�/1 �7VI i1Y� <br />