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�Gwo4t7138 ENVIRONMENTAL HEALTH <br /> PAGE 01/B3 <br /> [Rop* <br /> m 3/5/2011 1007:42AM SAN.' �1UIN COUNTY ENVIRONMENTAL HE -_)EPARTMENT pMalesoz+ <br /> Facility Information as of 3/5/2012 Rogel <br /> Nemrd SNembn CrN . Feeney ID FA001445y <br /> 1� Make ehangaslconwillons in RED Ink. <br /> 4;wV INFORMATION CHANGE(data) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(dale) <br /> SSN/Fed Tax ID <br /> Owner ID OW 0011499 New Owner 10 <br /> Owner Nome - <br /> Owner DBA CE -' - J °--1 -'--Z-Ej/ k <br /> Owner Address 7 7 0 <br /> STOGI4 , 95 2 U.: t-,:) / Fr- /f',: r. �•r. <br /> Home Phone NotSpeCified ';Oe' r:ic,. <br /> Work/Business Phone 209.464-94.20- <br /> Mailing Address 731 E MINER AVE CA <br /> STOCKTON, CA 95202 <br /> Care Of V c <br /> FACILITY FILE INFORMATION qR _5 2012 <br /> Facility lD FA0014457 -:r,10AOlpi:COtk�+ '• <br /> Facility Name SANDOVA6-AU-TOSERVICE u'r '= / W (QUN <br /> Location X731-FANNER AVS' 9 I — -QUIN fflVIC <br /> STOCKTON,CA 95202 / �,;• ' i`' �) E3 <br /> PhD- 2M464-9120 xO <br /> Mailing Address 731 E MINER AVE <br /> STOCKTON. CA 95202 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fox <br /> APN Entail: W 6S; V ItJ tq <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name J/c,,/C1•'� L.%� 7 <br /> Title <br /> Day Phone _ ifJ`:i r Vii'd' — !. , 1• <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0024537 New Account ID <br /> Mail Invoices to Owner Mai Invoices to: Owner / Facility / Account <br /> Account Name EVANGELINA SANDOVAL a el <br /> Account Balance as Of 3/512012: $219 00 <br /> IC�rcb Onef <br /> I`mgrnm/Elnn hroopd Dnaetp%on Reeab 10 Empbyae ID and Mme lilpyn New Own Do" ve <br /> 2244-PACT TRANSFER RECORD-OES PRO519315 EE0000000-HAZ MAT SJCI ES Active y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPR0530e49 Active Y N A t D <br /> BILLING end COMPLIANCE ACKNO14LEOGEMENT1.the Nndealgnod weer,WontW,pent orseme.6IXItUMedpe that oh Nb,ondlx pntj c sPedfb.RNS/Ele)h Hy charos siwcialed with this <br /> IadNiy er iv.YMN wa�dwl b Ue pMry beMaetl es me OMMER en INo law I Nro cMlfy mel ex epemtlpne will he perramee h eeteleYteD wlln ell sPPI1cIWe Ordlneu Codss Ind/a SlrodeM ane <br /> 519M endlM TMmel SIM. <br /> APPLICANT'S SIGNATURE: �LL44,11 •�� y4-1.- Data <br /> Program Records to be TRANSFEREO: a$25.00= Amount Paid 09% 1_J_ <br /> Water System to W TRANSFERED: AmountPaitl Date <br /> Payment Type Check Number Received by <br /> RENS: R, VbA k! Date f_ _/_12, Account out: DateI_! <br /> COWEWS: <br /> Pfau- N �Z, off( <br /> FTS P 2 2 �r LZ <br /> l4Ih-envlenvtSlomreponSZ021.rpt <br />