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Date run 7/20/2016 2:20:031pM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 95021 <br /> Run by <br /> Facility Information as of 7/20/2016 Pagel <br /> Record Selection Criteria: Facility ID FA0014688 <br /> Make changestcorrections 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 OW0011699 New Owner ID <br /> Owner Name Casey Haynes <br /> Owner DBA DANS TIRE &AUTO REPAIR LLC <br /> Owner Address 1533 S STOCKTON STA <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-334-2969 <br /> Mailing Address 1533 S STOCKTON ST <br /> LODI, CA 95240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0014688 10184741 <br /> Facility Name DANS TIRE&AUTO REPAIR LLC <br /> Location 1533 S STOCKTON ST <br /> LODI, CA 95240 <br /> Phone 209-334-2969 x <br /> Mailing Address 1533 S STOCKTON ST <br /> LODI, CA 95240 <br /> Care of Casey Haynes <br /> Location Code 02-LODI Alt Phone <br /> BOS District 004-WINN, CHARLES Fax <br /> APN 06251004 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 AR0024995 �; a" I-,61Z New Account ID: <br /> Mail Invoices to Account ��//// Mail Invoices to: Owner / Facility / Account <br /> Account Name DANS TIRE &AUTO REPAIR LLC i IL (Circle One) <br /> ///��� <br /> Account Balance as of 7/20/2016: $1,241.00 V � <br /> (Circle One) <br /> Transfer to ActiveMachas <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO521614 EE0008709-JAMIE LIMA Active Y N A D <br /> 2220-SM HW GEN<5 TONS/YR PRO538435 EE0000005-FATINAH ZAREEF Active Y N A D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO528784 EE0002622-BENJAMIN ESCOTTO Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE PR0534418 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anNor project specific,PHSEHD hourly charges associated with this facility <br /> or activity will be billed to the party ident�ed as the OWNER on this form. I also cer ify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State andlor <br /> 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 TyRe Check Number Received by <br /> EHD Staff: t,l�(lf. Date Account out: Date <br /> COENTS: <br /> Invoice#: <br />