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Date fun 2/24/2014 2:26:16PA SAN JO&IIN COUNTY ENVIRONMENTAL HEA>�DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/24/2014 <br /> Record Selection Criteria: Facility ID FA0020699 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0017008 New Owner ID <br /> Owner Name HAjB+p}g-g{ & �rv.a. AR i <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 lD/CERS ID FA0020699 10,187,673 <br /> Facility Name PRO-SMOG AUTO REPAIR <br /> Location 9170 THORNTON RD <br /> STOCKTON, CA 95209 <br /> Phone 209-478-7872 x0 <br /> Mailing Address 9170 THORNTON RD <br /> STOCKTON, CA 95209 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District 003 - BESTOLARIDES Fax <br /> APN 07245021 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 AR0037116 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name HA43tNp-� (Circle One) <br /> Account Balance as of 2/24/2014: $333.00 <br /> (Circle One) <br /> Transfer to Acgveiinactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0535940 EE0006044-LOWELL ALLEN Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0538607 EE0004636-GARRETT BACKUS Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO535987 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 speck,PHSIEHD 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 and'or Standards and State andror <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 Type Check Number Recei��¢'�y <br /> REHS: Date 7L 7,4/ Account out: l Date <br /> COMMENTS: <br />