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Date run 3/14/2016 3:05:13PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 3/14/2016 <br />Record Selection Criteria: Facility ID FA0015571 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0012520 <br />Owner Name <br />HUSSAIN, IQBAL <br />Owner DBA <br />STOCKTON, CA 95205-2956 <br />Owner Address <br />2272 E WATERLOO RD <br />STOCKTON, CA 952052956 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />510-695-7566 <br />Mailing Address <br />2272 E WATERLOO RD <br />Alt Phone <br />STOCKTON, CA 95205 <br />Care of <br />APN 14116029 <br />II_T01111111 tiA1L�G17e1ala" T-Alrel`.I <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN /Fed Tax ID <br />New Owner ID : <br />Facility ID / CERS ID FA0015571 10184989 <br />Facility Name WATERLOO AUTO REPAIR <br />Location 2272 E WATERLOO RD <br />STOCKTON, CA 95205-2956 <br />Phone 209-451-3917 x <br />Mailing Address 2272 E WATERLOO RD <br />STOCKTON, CA 95205 <br />Care of HUSSAIN, IQBAL <br />Location Code 99 - UNINCORPORATED P <br />Alt Phone <br />BOS District 001 - VILLAPUDUA, CARLOS <br />Fax <br />APN 14116029 <br />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 AR0026871 <br />New Account ID: <br />Mail Invoices to Account <br />Mail Invoices to: Owner / Facility / Account <br />Account Name WATERLOO AUTO REPAIR <br />(Circle One) <br />Account Balance as of 3/14/2016: $248.00 <br />(Circle One) <br />Transfer to Active/Inactve <br />rFT ogram/Element and Description Record ID <br />Employee ID and Name Status New Owner? Delete <br />HMBP-Regular-Primary Location PR0529922 <br />EE0000006 - HAZA SAEED Inactive Y N I D <br />2220 - SM HW GEN <5 TONS/YR PR0524295 <br />EE0000027 - CINDY VO Active Y N A I D <br />3122 - STORMWATER INSPECTION - AUTO SHOP PR0523071 <br />EE0009488 - JEFFREY WONG Inactive Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0531408 <br />Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD 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 es an dards 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 Type Check Number Received by <br />EHD Staff: Date / Account out: b6 Date 3 05 0(0 <br />COMMENTS: o <br />Invoice #: x'77 0 <br />%cS�-� �%��--. � !i-� ��-�-�`. �.v,,- -1-��}./y�g��,///cwt' e�ryti,e,.�^>�5 S �:9•.—/,��� //_/ �C�% <br />