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Date run 1/9/2013 4:50:26PMReport#5021 <br /> SAN JOi�7N COUNTY ENVIRONMENTAL HEALh.fDEPARTMENT <br /> Run by <br /> Facility Information as of 1/9/2013 Page'. <br /> Record Selection Criteria: Facility ID FA0007952 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner lD OW0006574 New Owner ID <br /> Owner Name MARTINI'S AUTOMOTIVE <br /> Owner DBA MARTINI'S AUTOMOTIVE <br /> Owner Address 4032 N EL DORADO ST <br /> STOCKTON, CA 95203 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-462-8696 <br /> Mailing Address 4032 N ELDORADO ST <br /> STOCKTON, CA 95204 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0007952 <br /> Facility Name MARTINI AUTO <br /> Location 4032 N EL DORADO ST <br /> STOCKTON, CA 95204 <br /> Phone 209-462-8696 <br /> Mailing Address 4032 N EL DORADO ST <br /> STOCKTON, CA 95204 <br /> Care of <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOIS District 001 -VILLAPUDUA Fax <br /> APN 11518501 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0014728 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name MARTINI AUTO (Circle One) <br /> Account Balance as of 1/9/2013: $0.00 <br /> (Circle One) <br /> Transferto Activellnadve <br /> Progra"Element and Description Record ID Employee ID and Name Status New Ovmer7 Delete <br /> 1920-HMBP-Common Materials PR0520481 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO514410 EE0004636-GARRETT BACKUS Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOtPRO513059 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0508130 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPRO510771 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPRO534782 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor proled specific,PHS/EHD 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 ander Standards and State and'ar <br /> Federal Lewis <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 /> RENS: Date I / Account out: Date <br /> COMMENTS: <br />