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Date run 10/19/2016 2:25:20F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 10/19/2016 <br />Record Selection Criteria: Facility ID FA0015324 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIRL <br />OWNER FILE INFORMATION Number of facilities for this owner02 2 SSN / Fed Tax ID <br />Owner ID OW0012300 New Owner ID <br />Owner Name Cqp—JAeK y S <br />Owner DBA <br />Owner Address 8814 FOX CREEK DR <br />STOCKTON, CA X249- 1!51 <br />Home Phone 209--922--4-577— �i — —5, <br />Work/Business Phone 21" -2G -4b / / <br />Mailing Address 88T4 -FO -CREEK-D \\ <br />STOCKTON, C- A � l'� ,L J -- <br />Care of C-AO-JAGf(- <br />L -� _ /',/► �iJ -,��_ <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0015324 10184921 <br />Facility Name k AQ )v .+ <br />Location 3403 E MAIN ST STE B <br />STOCKTON, CA 95205 �+ <br />Phone '2 �9-92-2--4-5�X 7 <br />Mailing Address 3403 E MAIN ST STE B <br />STOCKTON, CA 95205 <br />Care of C� A-e;X <br />Location Code 01-STOCKTON Alt Phone <br />BOS District 001 - VILLAPUDUA, CARLOS Fax <br />APN 15717017 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 AR0026382 New Account ID: <br />Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br />Account Name N's AUTO REPAIR (Circle One) <br />Account Balance as of 10/19/2016: $0.00 <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 PR0527148 EE0000006 - HAZA SAEED Inactive YI D <br />2220 - SM HW GEN <5 TONSNR PR0522503 EE0000015 - TIMOTHY ENGLE Inactive Y I D <br />4740 - WASTE TIRE SITE - EXEMPT PR0522461 EE0009000 - HARPRIT MATTU InactivE Y N I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PRO534676 Inactive Y N 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 fory 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 />APPLICANTS SIGNATURE. � Date —1d / / <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: Date 10 1—/_�/� Account out:y/ Date <br />COMMENTS: /] (� 1 V r7 / (//( Invoice #: <br />J <br />