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Date nun 9/15/2014 9:06:49AR SANJO�JIN COUNTY ENVIRONMENTAL HEAJ&DEPARTMENT Report#5021 <br /> Run by pagvL <br /> Facility Information as of 9/15/2014 <br /> Rewid Selection Catena: Facility ID FA0016552 <br /> Make changes/corrections 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 01/1/0013407 New Owner ID <br /> Owner Name BARAJAS, GRISELDA <br /> Owner DBA CORONA PM ROAD SERVICE <br /> Owner Address 1887 E 11TH ST <br /> STOCKTON, CA 95206 <br /> Home Phone 209-495-0768 <br /> Work/Business Phone 209-932-0598 <br /> Mailing Address 1887 E 11TH ST <br /> STOCKTON, CA 95206 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0016552 10185189 <br /> Facility Name CORONA PM ROAD SERVICE <br /> Location 2327 MARIPOSA RD <br /> STOCKTON, CA 95205 <br /> Phone 209-932-0598 <br /> Mailing Address 2327 MARIPOSA RD <br /> STOCKTON, CA 95205 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 17129016 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 AR0029189 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name BARAJAS, GRISELDA (CirdeOne) <br /> Account Balance as of 9/15/2014: $0.00 <br /> (Circle One) <br /> Transfer to AdiveAnadve <br /> PrograMElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO524649 EE0000006-HAZA SAEED Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0538510 EE0001421 -STACY RIVERA Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO524826 EE0000060-JENNIFER FRASE Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO531397 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge met all site,andor project specific,PHSEHD hourly charges associated with this facility <br /> or activity will W 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 Codas andor Standards and State ands <br /> Federal Lewis <br /> APPLICANTS SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date /_/_ <br /> Water System to be TRANSFERED: Amount Paid Dale <br /> Payment Type Check Number Received by <br /> RENS: Date / /_ Account out: Date <br /> COMMENTS: <br />