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Date run 8/28/2015 7:56:48AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 8/28/2015 <br />Record Selection Criteria: Facility ID <br />FA0023068 <br />Make changes/correction to RED ink. <br />INFORMATI HANGS <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION <br />Number of facilities for this owner: 1 <br />SSN / Fed Tax ID <br />Owner ID <br />OW0021118 <br />New Owner ID <br />Owner Name <br />RODRIGUEZ, ALEX <br />Owner DBA <br />CAR CLUB AUTO REPAIR <br />Owner Address <br />374 W 21 ST ST <br />TRACY, CA 95376 <br />Home Phone <br />209-613-5926 <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />374 W 21 ST ST <br />TRACY, CA 95376 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0023068 <br />Facility Name <br />CAR CLUB AUTO REPAIR <br />Location <br />24552 S MAC ARTHUR DR'� <br />�SoZ S MncPr2YHJR <br />TRACY, CA 95376 <br />Phone <br />209-839-8280 <br />Mailing Address <br />24552 S MAC ARTHUR DR <br />TRACY, CA 95376 <br />Care of <br />RODRIGUEZ, ALEX <br />Location Code <br />Alt Phone <br />BOS District <br />Fax <br />APN <br />25024001 <br />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 <br />AR0042341 <br />New Account ID: <br />Mail Invoices to <br />Facility <br />Mail Invoices to: Owner / Facility / Account <br />Account Name <br />CAR CLUB AUTO REPAIR <br />(Circle One) <br />Account Balance as of 8/28/2015: <br />$191.50 ,,10a4.,89,�% <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1920 - HMBP-Common Materials PR0540350 EE0000010 - PETER LOMBARDI Active Y N AI D <br />2220 - SM HW GEN <5 TONS/YR PR0540349 EE0002646 - THUY TRAN Active Y N A D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andfor 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 and/or Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: 9L Date <br />Program Records to be TRANSFERED: " $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Type Check Number Received by <br />EHD Staff: Gj�i �= Date �/ �`l / S Account out: Date 1 <br />COMMENTS: <br />Invoice #. <br />SSS 1D Y <br />02,0 <br />�t f <br />