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Ostend, 61 425:311 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1*5021 <br />D0 by <br />Facility Information as of 6/26/2017 Pqat <br />R.M Seleciion Coterie: Fenny In FA0013W <br />Make changes/comectlons 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 OW0010757 <br />Owner Name BRAVO, ANDRES <br />Owner DBA BRAVO BROS AUTO BODY <br />Owner Address 5174 E KETTLEMAN LN <br />LODI, CA 95240 <br />Houle Phone 209-475-2236 <br />Work/Business Phone Not Specified <br />Mailing Address 5174 E KETTLEMAN LN <br />LODI, CA 95240 <br />Care of BRAVO, ANDRES <br />FACILITY FILE INFORMATION <br />Facility ID? CERSID FA0013644 10184485 <br />Facility Name BRAVO BROS AUTO BODY <br />Location 720 E LODI AVE <br />LODI, CA 95240 <br />Phone 209-475-2236 <br />Mailing Address 720 E LODI AVE <br />LODI, CA 95240 <br />Care of BRAVO, ANDRES <br />Location Code 02 -LODI <br />SOS District 004 - WINN, CHARLES <br />APN 04745013 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />D'yn�is �y-+���c)hc� <br />All Phone <br />Fax <br />EMail : <br />Account ID AR0022800 New Amount ID: : <br />Mail Invoices to Facility Mail Invoices to'. Owner I Facility I Account <br />Account Name BRAVO BROS AUTO BODY a deon.> <br />Account Balance as of 6/2612017: $0.00 <br />(Cirde Olro? <br />0 <br />Tranito ACdvNlnecNa <br />PragreMEiemanl and iJeaaiption RewklO Employee lO eM Neme Stetae New Owner? OMW <br />T 1920 - HMBP-Common Materials PRO521048 EE0008709- JAMIE LIMA Active Y N AD <br />2220 - SM HW GEN <5 TONS/YR PRO517990 EE9999998 - ONE VACANTI Active Y N A9 D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PRO517991 EE0000000- HAZ MAT SJC OES Inactivc Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PR0517992 EE0000000 - HAZ MAT SJC OES Inactivc Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PRO532277 Inactivc Y N A 1 D <br />BILLING and COMPLIANCE AC NMLEDGEMENT: LVnunaaddjn*downer, operator nagatt of same, acknoMeOge Ilial en site, er,Nor protect sparillc,PH&EHD hourly alrardea asmo'9teU WhIhie raWiry <br />m a Wy ora be bled to Ne party idendeed as lire OW NER on this form also certify Nal all operadons mil7e pedo,med In accoNance wilb tll eppliuble Ordhanu Codas endor SlandaNs and Biala en6'or <br />Fedend La., <br />APPLICANTS SIGNATURE: DateI <br />" <br />Program Records to be TRANSFERED: ' $25.00 - Amount Paid Dale <br />Water System to be TRANSFERED: Amount Paid Date / r_ <br />Payment Type Check Number Received b �7 <br />7 <br />EHD Stag: Date �ll Account out: Date / l�/ / 1.-a <br />COMMENTS'. f Invoice #: .9q 0 -7 <br />Plai clkti 6 n9/r aS S 01i <br />27izJ, <br />