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Datemn 2/13/2017 1:25:15PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Rim by Pagel <br /> Facility Information as of 2/13/2017 <br /> Record Selection Criteria: Facility ID FA0000511 <br /> Make Changers/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 ID <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 /> BOS District 004 -WINN, CHARLES Fax <br /> APN 05814001 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name VIRK, 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 2/13/2017: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> ProgramlElement and DesorptionRecord ID Employee ID antl Name Status New Owner? Delete <br /> 1617-RETAIL MARKET>1000 SQ 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 � 1 D <br /> 2220-SM HW GEN<5 TONS/YR PRO534921 EE0000030-AARON HANG Inactive Y N I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534922 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACMOWLEDGEMENT: I,the undersigned owner,operator or agent of same,ackmovdedge that all site,andof project specific,PHSIEHO hourly charges associated with this feoany <br /> or w(wity will be WIW 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 andw standards and Bate andor <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 Type Check Number Received/hy <br /> EHD Staff: Date /_/3 l� Account out: Date �I /7 <br /> COMMENTS: <br /> 14 -hNU ab Invoice <br /> t- ✓q ��IDw <br /> wry e70ev *)P j; C7-4ex4s cam , <br /> t-c�Var —4lt7 T4 L.✓ �C+.,WA' •� !b1`Mr TS . <br />