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Date run 3/12/2018 8:29:04AIv SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report i1i <br /> Run by Pagel <br /> Facility Information as of 3/1212018 <br /> Record Selection Criteria: Facility ID FA0010162 <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 OW0008162 Case Number: H06985 N9ty Owner ID : <br /> Owner Name A15rF_— / 0 YM nsrp <br /> Owner DBA r' <br /> Owner Address —^^" ^ ^"" <br /> V �w Gi.0-a-1S- <br /> Home Phon�� a?)V l tea()—t0 62 <br /> Work/Business Phone -2e9_g6gw7j-7S— �'40cl C1 3 )- 1 IV() <br /> Mailing Address 2953 CHERRYLANDAVE#B <br /> STOCKTON, CA 952152233 <br /> Care of.4 AfN Rt7V/A yE--- ) h h LA )Vh()Srm <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0010162 10183281 <br /> Facility Name OFF I E)AB EN E cP ,lv 1 rje' 1 IA <br /> Location 2953 CHERRYLAND AVE STE B <br /> STOCKTON, CA 95215 <br /> Phone 209-931-1170 <br /> Mailing Address 2953 CHERRYLAND AVE STE B <br /> STOCKTON, CA 952152233 <br /> Care of-MAR_T4N,-VVA9& U Styy�hS�m <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 08710046 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION _ <br /> Contact Name iU-Aa-��AadLo ` , U f 14 S; <br /> Title Owner �j f <br /> Day Phone 420q_93}.g}3-7- W —1 <br /> Night Phone.8 Arw ACCOUNTS RECEIVABLE FILE INFORMATION , S � �1Account ID AR0017162 n� ( New Account ID: <br /> Mail Invoices to Account ,V_'p \ n I Mail Invoices to: Owner / Facility / Account <br /> Account Name OFF ROAD E RPRISES VVVp� (Circle One) <br /> Account Balance as of 3/12/2018: $8, 9.15 ,U�\\\ <br /> Q (Circle Ona) <br /> Transfere Activaunactve <br /> ate <br /> �ogmmlElement and Description Re ID Employee ID and Name Status New OwneR Delete <br /> SB HMBP-Regular-Primary Locetiol�2 C-ft n) PR0620111 EE0008709-JAMIE LIMA Active Y N A I D <br /> 1240- M HW GEN<5 TONSNR PR0514207 EE0000031 -ELIANNA FLORIDO Active Y N A I D <br /> Wr^2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512450 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE Fl PR0510162 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 3122-STORMWATER INSPECTION-AUTO SHOP PRO522966 EE0004636-GARRETT BACKUS Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE PRO532890 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anclor project speck,PHS/EHO hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this farm. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes anclor Standards and State andlor <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 Tyew, 'AAA � Check Number Received <br /> EHD Staff: �'•T"'" Date I L' l Account out: Date <br /> C MMENTS: <br /> Invoice#: 3 0 S7,2-7 <br />