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Date run 10/17/2016 8:50:42A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report x5021 <br /> Run by Pagel <br /> Facility Information as of 10/17/2016 <br /> Record Selection Criteria; Facility ID FA0014882 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 SSN/Fed Tax ID : <br /> Owner ID OW0011888 Ne Owner ID <br /> Owner Name tptpgy <br /> Owner DBA �n 1 <br /> Owner Address 330 E KETTLEMAN LN <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone ^^.366 u,-,T UQ ZZrk <br /> Mailing Address 330 E KETTLEMAN LN <br /> LODI, CA 95240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0014882 <br /> Facility Name 6nio-^t Oisci1 Ire. <br /> Location 330 E KETTLEMAN LN <br /> LODI, CA 95240 <br /> Phone 7f) Z77 <br /> Mailing Address 330 E KETTLEMAN LN <br /> LODI, CA 95240 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0025408 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name (Circle One) <br /> Account Balance as of 10/17/2016: $0.00 <br /> (Circle One) <br /> Transfer to Activerinac e, <br /> lament and Description Record ID Employee ID and Name Status New owner'! Details <br /> �-HMBP-Regular-Primary Location PRO521898 EED008709-JAMIE LIMA Inactive Y N I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all see,and'or project specific,PHSIEHD hourly charges associated with this facility <br /> or adwy will be billed to the party identiked as the OWNER on this form. I also cer@y that all operations will be performed In accordance with all applicable ordinance Codes ai Standards and State ani <br /> 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 TypPe,� Check Number Receive <br /> EHD Staff: LA Date / / U Account out: Date /2 / i <br /> CCOOMMEN•T& �/�/�/� j /J� p/fit ,I�/—) <br /> Oil � �Q�' 1rVrrl IUO S ' saVPUImw� . Invoice ll: <br /> kI � WWOAJ OUi�i►j �W �V %S acG0,,nt". 1222 .00 <br />