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Date run 7/15/2016 2:18:49P(v SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5027 <br /> Run by <br /> Facility Information as of 7/15/2016 Pagel <br /> Record Selection Caere: Facility ID FA0020699 <br /> Make changeslcorrections 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 OW0017008 New Owner ID <br /> Owner Name ALI, IMAN <br /> Owner DBA PRO-SMOG AUTO REPAIR <br /> Owner Address 9170 THORNTON RD <br /> STOCKTON, CA 95209 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-478-7872 <br /> Mailing Address 9170 THORNTON RD <br /> STOCKTON, CA 95209 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0020699 10187673 <br /> Facility Name PRO-SMOG AUTO REPAIR <br /> Location 9170 THORNTON RD <br /> STOCKTON, CA 95209 <br /> Phone 209478-7872 x0 <br /> Mailing Address 9170 THORNTON RD <br /> STOCKTON, CA 95209 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District 003- BESTOLARIDES, STEVE Fax <br /> APN 07245021 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 AR0037116 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name ALI, IMAN (Circle One) <br /> Account Balance as of 7/15/2016: $0.00 <br /> (Circle One) <br /> Program/Element and DescdptionRecord ID Employee ID and Name Status Transfer to ActivellnacNe <br /> New Owner? Delete <br /> 1920-HMBP-Common Materials PRO635940 EE0008709-JAMIE LIMA Active Y N AD <br /> 2220-SM HW GEN<5 TONS/YR PRO538607 EE0001459-VICKI MCCARTNEY Active Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0535987 Inactive Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,adanowledge that all site,andior project speck,PHSrEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes anNor Standards and State and'or <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 Tyne Check Number Received <br /> EHD Staff: t�1 Vy\pit_ Date 15--/Ap—Account out: Date�_/��/& <br /> COMMENTS: <br /> 6?OrA` ,� Ct (�_ ,_ _ri _ S I,�r1 a� Invoice#: <br /> ue�1 f wive--6. (f <br />