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Date run 4/12/2016 3:28:44PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 4/12/2016 <br />Record Selection Criteria: Facility ID FA0005173 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0004045 <br />Owner Name <br />Gurpreet Singh <br />Owner DBA <br />ALPINE SMOG & AUTO SALES INC <br />Owner Address <br />305 W LODI AVE <br />LODI, CA 95240 <br />Home Phone <br />209-200-0259 <br />Work/Business Phone <br />209-200-0259 <br />Mailing Address <br />305 W LODI AVE <br />Active <br />LODI, CA 95240 <br />Care of <br />AD <br />9 <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0005173 10181757 <br />Facility Name Alpine Smog and auto sales inc <br />Location 305 W LODI AVE <br />LODI, CA 95240 <br />Phone 209-334-2898 x <br />Mailing Address 305 W LODI AVE <br />LODI, CA 95240 <br />Care of Gurpreet Singh <br />Location Code 02 - LODI <br />Bos District 004 - WINN, CHARLES <br />APN 037-300-200-00( <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID : <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0005621 New Account ID: <br />Mail Invoices to Account Mail Invoices to: Owner / <br />Account Name Gurpreet Singh <br />Account Balance as of 4/12/2016: $0.00 <br />Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/lnactve <br />Program/Element and Description <br />Record ID <br />Employee ID and Name <br />Status <br />New Owner? <br />Delete <br />1921 - HMBP-Regular-Primary Location <br />PR0540621 <br />EE0008709 - JAMIE DE LA ROSA <br />Active <br />Y <br />N <br />AD <br />9 <br />2220 - SM HW GEN <5 TONS/YR <br />PR0534934 <br />EE0001422 -ARIS VELOSO <br />Active <br />Y <br />N <br />A D <br />2381 - UST FACILITY (BEFORE 1/84) - obsolete <br />PR0501639 <br />EE0000005 - FATINAH ZAREEF <br />Inactive <br />Y <br />N <br />A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGE <br />PR0535296 <br />Inactive <br />Y <br />N <br />A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT. I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or 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 andlor Standards and State andfor <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: " $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Ty e� Check Number Received 4yz,,n/ <br />EHD Staff:, Date /IL / Ile Account out: Date 41 12—/_� <br />OMMENTS: /1 <br />p (r� LL <br />Invoice #: <br />