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Date 1/27/2014 9:19:28AN SAN JO, AN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report 95021 <br /> R <br /> Facility Information as of 1/27/2014 Pagel <br /> Record Selection Criteria: Facility ID FA0014688 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0011699 New Owner ID <br /> Owner Name HALL, CLIFF <br /> owner DBA DANS TIRE&AUTO REPAIR LLC <br /> Owner Address 1533 S STOCKTON ST `j1- <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 to 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 <br /> Mailing Address 1533 S STOCKTON ST <br /> LODI, CA 95240 <br /> Care of HALL, CLIFF <br /> Location Code 02-LODI Alt Phone <br /> BOIS District 004-VOGEL, KEN Fax <br /> APN 06251004 Entail: <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 New Account ID: <br /> Mail Invoices to: Owner / Facility / Account <br /> Mail Invoices to Facility <br /> (Cil One) <br /> Account Name DANS TIRE&AUTO REPAIR LLC <br /> Account Balance as of 1/27/2014: $0.00 (Clyde One) <br /> Transfer to Active/InacNe <br /> Program/Element and Description <br /> Record ID Employee ID and Name Status New OwnaR Delete <br /> 1920-HMBP-Common Materials PRO521614 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO528784 EE0002620-ALFONSO ARAMBULA Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO534418 Inactiv[ Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undenigned owner,operator or agent of same.acknowledge that ail site,ander project specific,PHSrEHD hourly charges ass,xiated with this faolity <br /> or activity will be billed to the WY identified as the OWNER do this form. I also certify that all operations will be garrisoned in accordance with all applicable Ordinance Codes andor Standards and State ander <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment'r pe Check Number Received by <br /> RENS: t P ti iJ Snst� _ Date�_/j2 /� Account out: Wg Date `f <br /> COMMENTS:O � <br /> f�E 22Z0 <br /> 1�. <br />