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Date run 2/11/2014 4:01:10Ph SAN JUIN COUNTY ENVIRONMENTAL HEA&DEPARTMENT <br /> Run byr. 12n Report#5021 <br /> Facility Information as of 2/11/2014 Pagei <br /> Record selection Criteria: Facility ID FA0019950 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> SSN/Fed Tax ID <br /> Owner ID <br /> OW0016373 New Owner ID <br /> Owner Name ANDREW PO LLINO <br /> Owner DBA PRO CARE AUTOMOTIVE <br /> Owner Address 9457 THORN ON RD <br /> STOCKTON, CA 95299p�n ) ?— <br /> Home PhoneI�ocr' 7�3 <br /> Not Specified <br /> Work/Business Phone 209-472-9866 <br /> Mailing Address 9457 THORNTON RD <br /> STOCKTON, CA sr}zes95ala:�7 �3 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility to/CERSID FA0019950 10,187,457 <br /> Facility Name PRO CARE AUTOMOTIVE <br /> Location 9457 THORNTON RD <br /> STOCKTON, CA 95209 <br /> Phone 209-472-9866 x0 <br /> Mailing Address 9457 THORNTON RD nQ 9RAJ A m 0 �- <br /> STOCKTON, CA 9&2QcL.g60 `N 70 <br /> . Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 003- BESTOLARIDES Fax <br /> APN 08027001 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 AR0035529 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name ANDREW POLLINO (Circle One) <br /> Account Balance as of 2/11/2014: $348.00 <br /> (Circle One) <br /> Program/Element and Description Record ID Employee ID and NameTransfer to Active/Inactve <br /> Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0530794 EE0006044-LOWELL ALLEN Active Y N A I D <br /> 2220-SM HW GEN<5 TONSNR PR0538599 EE0004636-GARRETT BACKUS Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534705 Inactiv< Y N A I D <br /> BILL <br /> CE <br /> LEDGEMENT. 1,the <br /> or actlNGyawdl be billed A ,idommea as the OWNER onthisform IasorceRdy that all erator or operations will beent of same, knowledge pa performed int all site,accordancewith project PHSIEHD hourly <br /> ordinance Codes nd'orStandards and state end/" <br /> pan,i <br /> Federal Laws. i <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: $25.00 ie Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment TypeREHSCheck Number Recei <br /> COMMENTS <br /> Date /_/_ Account out: <br /> COMMENTS: � —_ <br /> V _ <br />