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Datemn 5/8/2017 12:13:16PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 1i <br /> Run by Pagel <br /> Facility Information as of 5/8/2017 <br /> Record Selection Criers Facility ID FA0000511 <br /> Make changes/corrections 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 OW0000422 New Owner 10 <br /> Owner Name TEXAS CONVENIENCE MANAGEMENT SER <br /> Owner DBA ARCO AM/PM CMSI 3579 <br /> Owner Address PO BOX 6117 <br /> TEMPLE, TX 76503 <br /> Home Phone 512-298-0778 <br /> Work/Business Phone 360-808-3791 <br /> Mailing Address PO BOX 6117 <br /> TEMPLE, TX 76503 <br /> Care of MANNING, BJ <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0000511 10180609 <br /> Facility Name ARCO AM/PM CMSI#3579 <br /> Location 800 E KETTLEMAN LN <br /> LODI, CA 95240 <br /> Phone 209-334-3678 x <br /> Mailing Address PO BOX 6117 <br /> TEMPLE, TX 76503 <br /> Care of MANNING, BJ <br /> Location Code 02 - LODI Alt Phone <br /> BIDS District 004-WINN, CHARLES Fax <br /> APN 05814001 EMaiI: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name VI RK, RANA <br /> Title DISTRICT MANAGER <br /> Day Phone 360-808-3791 <br /> Night Phone 360-808-3791 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000510 New Account ID <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name ARCO AM/PM CMSI #3579 (Circle One) <br /> Account Balance as of 5/8/2017: $0.00 <br /> (Circle One) <br /> Transfer to Activesnadve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1617-RETAIL MARKET>1000 SO FT W/FOOD PREP PRO161886 EE0009488-JEFFREY WONG Active Y N A I D <br /> 1919-HMBP-0O2 Only Food Facility PRO540624 EE0009488-JEFFREY WONG Active Y N A ZD D <br /> 2220-SM HW GEN<5 TONS/YR PR0534921 EE9999998-ONE VACANTI Active Y N A 1i D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO534922 Inactivc Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project spec,PHS'EHD hourly charges associated with this facility, <br /> or activity will W 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 ander Standards and State ands <br /> Federal Laws. <br /> APPLICANTS 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 15�. / lZ ':2 Account out: ��_ Date <br /> COMMENTS: <br /> e) Invoice#: <br />