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Date run 9/24/2015 9:54:13AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 9/24/2015 <br />Record Selection Criteria: Facility ID FA0021888 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID OW0018025 <br />Owner Name MANCILLA, LITZEL <br />Owner DBA CHAVEZ TIRES <br />Owner Address 22212 MARIPOSA RD <br />ESCALON, CA 95320 <br />Home Phone 209-872-9049 <br />Work/Business Phone 209-809-6574 <br />Mailing Address 22212 MARIPOSA RD <br />ESCALON, CA 95320 <br />Care of MANCILLA, LITZEL <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0021888 <br />Facility Name <br />CHAVEZ TIRES <br />Location <br />4208 E MAIN ST <br />Status <br />STOCKTON, CA 95215 <br />Phone <br />209-809-6574 <br />Mailing Address 4208 E MAIN ST <br />STOCKTON, CA 95215 <br />Careof MANCILLA, LITZEL <br />Location Code <br />BOS District <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name MANCILLA, LITZEL <br />Title <br />Day Phone 209-809-6574 <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <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 />Account ID AR0039862 <br />Mail Invoices to Facility l / <br />Account Name CHAVEZTIP <br />3E9l <br />Account Balance as of 9/24/2015: $ 6.50 P_ <br />Program/Element and Description Record ID Employee ID and Name <br />1920 - HMBP-Common Materials <br />2220 - SM HW GEN <5 TONS/YR <br />4740 - WASTE TIRE SITE - EXEMPT <br />Mail Invoices to: <br />PR0540357 EE0000006 - HAZA SAEED <br />PR0540356 EE0000027 - CINDY VO <br />PR0537920 EE0009000 - HARPRIT MATTU <br />New Account ID: : <br />Owner / Facility / <br />(Circle One) <br />Account <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 and/or Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Type Check Number Received by <br />EHD Staff: Date / /�_ Account out: 116— Date / U <br />COMMENTS: � /'t{7 9/ res_ <br />J1`�" �'� .�--f�-t" -.�' �1�+1/Z�acS InvoicegL 101c <br />WV6 -k- 0- &4-4"(S leW tbi -bo �xzxh j& 03 of R/2Z1 S pec A�r <br />(Circle One) <br />Transfer to <br />Active/Inactve <br />Status <br />New Owner? <br />Delete <br />Active <br />Y N <br />A I$ D <br />Active <br />Y N <br />A D <br />Active <br />Y N <br />A 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 and/or Standards and State and/or <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 Type Check Number Received by <br />EHD Staff: Date / /�_ Account out: 116— Date / U <br />COMMENTS: � /'t{7 9/ res_ <br />J1`�" �'� .�--f�-t" -.�' �1�+1/Z�acS InvoicegL 101c <br />WV6 -k- 0- &4-4"(S leW tbi -bo �xzxh j& 03 of R/2Z1 S pec A�r <br />