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Date run 10/3112014 1:15:59F SAN JO. JIN COUNTY ENVIRONMENTAL HEA' ! DEPARTMENT Report#5021 <br /> Run by r..� �� Pagel <br /> Facility Information as of 10/31/2014 <br /> Record Seiectien Criteria: Facility ID FA0016348 <br /> Make changeslcorrections 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 1D <br /> Owner ID OW0013228 New Owner 10 <br /> Owner Name KENDRICK, HAROLD J <br /> Owner DBA LOCKEFORD AUTO <br /> Owner Address 4�-} <br /> 6 � C ZZ <br /> Home Phone 209-727-0800 <br /> Work/Business Phone 209-601-5851 <br /> Mailing Address PO BOX 214 <br /> CLEMENTS, CA 95237 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0016348 10185147 <br /> Facility Name LOCKEFORD AUTO <br /> Location 12962 BLOSSOM CT <br /> LOCKEFORD, CA 95237 <br /> Phone 209-727-0800 x <br /> Mailing Address 12962 BLOSSOM CT <br /> LOCKEFORD, CA 95237 <br /> Care of HAROLD KENDRICK <br /> Location Code 99 - UNINCORPORATED A Alt Phone <br /> Bos District 004 -VOGEL, KEN Fax <br /> APN 05131052 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 AR002$730 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility ! Account <br /> Account Name LOCKEFORD AUTO {Circle One) <br /> Account Balance as of 1013112014: $0.00 <br /> (Circle One) <br /> Transfer to Activeiinactve <br /> ProgramlEfemenit and Desrnplion Record 1D Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0524660 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2220-SM HW GEN e5 TONSIYR PR0524371 EE0001422-ARIS VELOSO Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0524686 EE0002620-ALFONSO ARAMBULA Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO533919 Inactivf 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 specific,PHSIEHD 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 andor Standards and State angor <br /> Federal Laws <br /> APPLICANT'S SIGNATURE: Date i / <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 y {—. <br /> RENS: Datel�6�I—� Account out: Date��1 f l f <br /> COMMENTS: <br />