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Date Ian 11/8/2017 2:34:52PIV SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 11/8/2017 <br /> Record Selection Criteria[ Facility ID FA0019310 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) 12-114 / <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID : <br /> Owner ID OW0015852 New Owner ID <br /> Owner Name MONTANO, KAREEMAH <br /> Owner DBA FAIRWAY AUTOMOTIVE REPAIR INC <br /> OwnerAddress 1768 COUNTRY CLUB BLVD <br /> STOCKTON, CA 95204 <br /> Home Phone 209-942-2915 <br /> Work/Business Phone 209-639-4803 <br /> Mailing Address 2136 report <br /> STOCKTON,,CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0019310 10187199 <br /> Facility Name FAIRWAY AUTOMOTIVE REPAIR INC <br /> Location 2735 TEEPEE DR STE 1A <br /> STOCKTON, CA 95205 <br /> Phone 209-942-2915 x <br /> Mailing Address 2735 TEEPEE DR STE b <br /> STOCKTON, CA 95205 <br /> Care of KAREEMAH MONTANO <br /> Location Code 99- UNINCORPORATED A Alt Phone` <br /> BOS District 002- MILLER, KATHERINE Fax <br /> APN 13208030 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 AR0034324 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name FAIRWAY AUTOMOTIVE REPAIR INC (Circle One) <br /> Account Balance as of 11/8/2017: $653.00 <br /> (Circle One) <br /> Program/Element and Description RecoM ID Employee lD and Name . Status Transfer to Activerinaclve <br /> New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO528747 EE0009817-ROBERT LOPEZ Active Y N AD <br /> 2220-SM HW GEN<5 TONSNR PR0535352 EE9999996-THREE VACANT3 Active Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO533200 - Inactive Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project speck,PHSEHO hourly charges associated with this facility <br /> or activity will be billed to the parry identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andror standards and Slate antler <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 Type Check Number Received b <br /> EHD Staff: - Z Date 7 Account out: Date 1 / <br /> COMMENTS: ' <br /> / Invoice#: <br /> /'t2 0 cc a <br />