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Date run 6/28/2016 3:35:28PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 6/28/2016 Pagel <br /> Record Selection Criteria: Facility ID FA0009370 <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 OW0007370 Case Number: H03539 New Owner ID <br /> Owner Name ROSE, DOUG <br /> Owner DBA KUSTOM KURVES COLLISION REPAIR <br /> OwnerAddress 1412 ARUNDEL CT <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-334-6803 <br /> Mailing Address 4 N HOUSTON LN <br /> LODI, CA 95240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0009370 10182635 <br /> Facility Name KUSTOM KURVES COLLISION REPAIR <br /> Location 4 N HOUSTON LN <br /> LODI, CA 95240-2420 <br /> Phone 209-334-6803 x <br /> Mailing Address 4 N HOUSTON LN <br /> LODI, CA 95240 <br /> Care of Douglas E Rose <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004-WINN, CHARLES Fax <br /> APN 04321040 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 AR0016370 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name KUSTOM KURVES COLLISION REPAIR (Circle One) <br /> Account Balance as of 6/28/2016: $0.00 <br /> (Circle One) <br /> Program/Element and Description Record ID Employee ID and Name Status Trensferlo Active/Inactve <br /> New Owner? Delete <br /> 1920-HMBP-Common Materials PRO521023 EE0008709-JAMIE LIMA Active Y N AI D <br /> 2220-SM HW GEN<5 TONS/YR PR0513795 EE0000005-FATINAH ZAREEF Active Y N A D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO511658 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PRO509370 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO531645 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andior project speck,PHS/EHD hourly charges associated with this facility <br /> ar 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 State ander <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 Tye Check Number Received <br /> EHD Staff: U M Q. Date / / Account out: Date_ e", / <br /> COMMENTS c I ( I _ I - / n <br /> IJ�A til r WJ �J �� "+, <br /> 11A41 1 I'I TLtQ 0' t t 10�r /1a.� 1/YtA kj_r . Invoice#: <br />