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Date run 2/8/2017 8:53:15AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 95021 <br /> Run by <br /> F <br /> Facility Information as of 2/8/2017 Papel <br /> Record Selection Criteria: Facility ID FA0019310 <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 OW0015852 New Owner ID <br /> Owner Name MONTANO, KAREEMAH <br /> Owner DBA FAIRWAY AUTOMOTIVE REPAIR INC <br /> Owner Address 1768 COUNTRY CLUB BLVD <br /> STOCKTON, CA 95204 <br /> Home Phone 209-942-2915 <br /> Work/Business Phone 209-639-4803 <br /> Mailing Address 24++-`:� - y2 <br /> s+o�{�}o,n CA 4sad�a o0 <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 P 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 (Cliche One) <br /> Account Balance as of 2/8/2017: $570.00 <br /> (Circle One) <br /> Transfer to Act velinact e <br /> PrograNElement and Description Record ID Employee ID and Name Status New Owrre() Delete <br /> 1921 -HMBP-Regular-Primary Location PRO528747 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO535352 EE0000023-PAULINE MANGRAI Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533200 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent d same,acknowledge that all site,andror project specific,PHSrEHD hourly charges associated with this reality <br /> or activity will be billed to Ne party identified as Me OWNER on this form. I also cenry that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State and'cr <br /> Federal Lower <br /> APPLICANTS SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> EHD Staff: Date /_/ Account out: Date .Z /$/ f <br /> COMMENTS: C/ <br /> Invoice#: <br /> Nla'tllrJo aJld�oss inko., Se aLs �la� t-a+Ur-h rnno. . <br />