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Date run 10/24/2017 2:51:14P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/24/2017 <br /> Record Selection Catena: Facility ID FA0018188 <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 OW0014928 New Owner ID <br /> Owner Name ABAWI, CAMRAN <br /> Owner DBA <br /> Owner Address 321 N STANISLAUS ST <br /> STOCKTON, CA 95202 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-346-5754 <br /> Mailing Address 321 N STANISLAUS <br /> STOCKTON. CA 95202 <br /> Care of ABAWI, CAMRAN <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0018188 <br /> Facility Name Stockton Collision Center <br /> Location 321 N STANISLAUS ST <br /> STOCKTON, CA 95202 <br /> Phone 209-346-5754 <br /> Mailing Address ST 5 K V isd <br /> ST&@*T0f- eA-95202 Fc 9 sd-od. -ate l <br /> Care of ABAWI, CAMRAN <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 13931034 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name _ <br /> Title O tJ (---t r`Gt'i -� <br /> Day Phone _ 5A � `IL li-o t/,- I CA SIS dos '2,a-3 � <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0031987 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Stockton Collision Center (Circle One) <br /> Account Balance as of 10/24/2017: $1,064.40 <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 PRO529899 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO526866 EE0001421 -STACY RIVERA Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532520 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSIEHO hourly charges associated with this facility or: <br /> be bided to the party identified as the OWNER on this form I also cartery that all operations will be performed in accordance with all applicable Ordinance Codes ander Standards and State ander Federal Laws, <br /> APPLICANT'S SIGNATURE: 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: Date/CZ/aq/J-1— <br /> COMMENTS <br /> -f 1-COMMENTS <br /> Invoice#: <br /> �t4�`vlJ fj unor- p-e!' r- t+nw � <br />