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ERmo�ld <br /> 10119/2017;12:02:11F <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Report#5021 <br /> Facility Information as of 10/19/2017 Pagel <br /> lection Cnteha: FA0010933 <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 <br /> SSN/Fed Tax ID <br /> Owner ID OW0008933 Case Number: H08999 New Owner to <br /> Owner Name OSORIO, HECTOR <br /> Owner DBA CONTINENTAL MUFFLER <br /> Owner Address 230 E LODI <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> WO Business Phone 209-368-1360 <br /> Mailing Address 230 E LODI AVE <br /> LODI, CA 95240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0010933 10183945 <br /> Facility Name CONTINENTAL MUFFLER <br /> Location 230 E LODI AVE n <br /> LODI, CA 95240 <br /> Phone 209-368-1360 x0 <br /> Mailing Address 230 E LODI AVE <br /> LODI, CA 95240 <br /> Care of HECTOR OSORIO <br /> Location Code 02 - LODI Alt Phone <br /> SOS District 004-WINN, CHARLES Fax <br /> APN 04719129 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name Hector OSorio <br /> Title Owner <br /> Day Phone 209-368-1360 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017933 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility I Account <br /> Account Name OSORIO, HECTOR t'.Ar Iy� (Circle one) <br /> Account Balance as of 10/19/2017:14M-G�� <br /> (Circe One) <br /> Program/Element and Description Record ID — Employee ID and Name Status Transfer to Active1na0ve <br /> New Owner? Delete <br /> 1920-HMSP-Common Materials PR0520868 EE0008709-JAMIE LIMA Active Y N A D <br /> 2220-SM HW GEN<5 TONSNR PR0514460✓ EE9999998-ONE VACANTI Active Y N AI D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO513221 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FE PR0510933 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE PR0532307 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that ail site,andor project spec,PHS(EHD hourly charges associated with this facility <br /> or activity will be billed to the party identfietl as the OWNER on this form. I also certify Nat all operations will be performed in accordance with ail applicable Ordinance Codes andar Standards and$tate ands <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 Tyge,. Check Number Received b <br /> COMMENTS: <br /> OM Staff: 1. Ma- Date / /� A000unt out: Date <br /> i3QSirll S no Irma has repU' a "+,�f (r <br /> Invoice#: <br /> Y►'v,VAo q aA� no U7gb�e- Gltic�miCa Qp <br />