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Date run 12/16/2016 9:48:47A SAN JOAQUIN COir'NTY EWMONWNTAL HEALTH DEPARTMENT Report#5021 <br /> Pagel <br /> Run by <br /> Iracility Information as of 12/1612016 <br /> Record Selection Criteria: Facility ID FA0011025 <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 OW0009025 Case Number: H09173 New Owner ID <br /> Owner Name NJSSR -S7\JT [ �� C,� <br /> Owner DBA :.7 <br /> Owner Address <br /> Home Phone Not Specified o <br /> Work/Business Phone 25q=477_-5ftn C2-6 <br /> Mailing Address 618 W FREMONT ST <br /> STOCKTON, CA 95203 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0011025 <br /> Facility Name tN7 z o <br /> Location 618 W FREMONT ST <br /> STOCKTON, CA 95203 <br /> Phone 249-g43-2966— 7 <br /> Mailing Address 618 W FREMONT ST <br /> STOCKTON, CA 95203 BOB PACE <br /> Care of Own <br /> Location Code 01 -STOCKTON <br /> BOS District 001 -VILLAPUDUA, CARLOS <br /> APN 20782-5 - Auto Tech Service <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title 618 W Fremont St., Stockton, CA 95203 <br /> Day Phone (209)464-9745-www.atsofstockton.com <br /> Night Phone atsofstocktoncaol.com <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> New Account ID: <br /> Account ID AR0018025 <br /> Mail lnvoicesto Account Mail Invoices to: Owner / Facility / Account <br /> Account Name FREMONT AUTO SERVICES (Circle One) <br /> Account Balance as of 12/16/2016: $0.00 (Circle One) <br /> Transfer to ActiveMadve <br /> PM/Element and Description <br /> Record ID Employee ID and Name Status New Owner? Delete <br /> { -HAZ MAT BUSINESS PLAN AUTHORIZATION PRO513313 EE000o000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0511025 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,adnowledge that all site,ansor project 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 andror Standards and Stale anclor <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 Typ Check Number Received by <br /> EHD Staff: T Date -�11t1 Account out: Date <br /> COMMENTS: Invoice#: <br />