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Date mn 1/21/2004 4:11:57Ph SAN JOA'TIN COUNTY ENVIRONMENTAL HEAL"•'-DEPART MF Report#5021 <br /> Rur%y <br /> Facility Information as of 1/21/200 <br /> Record Selection Criteria: Facility ID FA0003531 ' <br /> Make changeslcorrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION too <br /> Owner ID OW0002638 New Owner ID <br /> Owner Name K yD S• AJJG- <br /> Owner DBA BEST CLEANERS <br /> Owner Address 97 o Z 4.1.!T6 <br /> 6A91�6,�9544a— L�-IC �o acs c�i9 9S G�-Lf <br /> Home Phone (,nql 3L9 �PIeS <br /> Work/Business Phone 209-369-2865 <br /> Mailing Address 541 N HUTCHINS ST <br /> LODI, CA 95240 <br /> Care of BEST CLEANERS <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0003531 <br /> Facility Name BEST CLEANERS <br /> Location 541 N HUTCHINS ST <br /> LODI, CA 95240 <br /> Phone 209-369-2865 <br /> Mailing Address 541 N HUTCHINS ST <br /> LODI, CA 95240 <br /> Care of BEST CLEANERS <br /> Location Code 02-LODI APN: <br /> BOB District 004 -SEIGLOCK, JACK SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003109 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility ! Account <br /> Account Name BEST CLEANERS (Circle One) <br /> Account Balance as of 1/21/2004: $0.00 <br /> Transfer to (Circle One) <br /> ActivwInacNe <br /> Program/Element and Description Record ID Employee ID and Name Status New OwneO Delete <br /> 2381 -UST FACILITY(BEFORE 1/84) PR0232385 EE0003580-MICHELLE LE 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 speck,PHS/EHO hourly charges associated with this <br /> facility or activity wit 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 <br /> Stale and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / ! <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$155.00= Amount Paid Date <br /> Payment Type Check Number Received by [! <br /> REHS: Date / / Account out: Date�/ z3 /_L <br /> COMMENTS: <br /> \\Phs�hsgl-nt\apps\Envisions\Reports\5021.rpt <br />