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bate run ' 3%19/2013 2:19:04Ph SAN JO IN COUNTY ENVIRONMENTAL HEAI.DEPARTMENT Repan#5021 <br /> Run by Paget <br /> Facility Information as of 3/19/2013 <br /> Record Selection Criteria: Facility ID FA0018096 <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 OW0008945 Case Number: H09025 New Owner ID : <br /> Owner Name PAIZS, BYRON J <br /> Owner DBA <br /> Owner Address 6245 BURSON RD <br /> VALLEY SPRINGS, CA 95252 <br /> Home Phone 209-772-1785 <br /> Work/Business Phone 209-957-5226 <br /> Mailing Address 2354 WILCOX RD <br /> STOCKTON, CA 95215-2318UA )Cox <br /> Care of PAIZS, BYRON J CAZ <br /> FACILITY FILE INFORMATION <br /> Facility to/CERS ID FA0018096 10,186,755 <br /> Facility Name TULEBURG TOWING <br /> Location ^n nc n W r GE`R9 <br /> STOCKTON, CA 95215 <br /> Phone 209-931-6181 / <br /> Mailing Address 2354 WILCOX RD <br /> STOCKTON, CA 95215-2318 <br /> Care of PAIZS, BYRON J <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 10102174 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 AR0031831 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name TULEBURG TOWING (Circle One) <br /> Account Balance as of 3/19/2013: $623.00 <br /> (Circle One) <br /> Transfer to Acbvwlnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Omer' Delete <br /> 1921 -HMBP-Regular-Primary Location PRO636641 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO526727 EE0009488-JEFFREY WONG Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO527978 EE0007379-AMANDA BOERTIEN Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCRPR0534307 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identifiep..the OWNER on this form I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andior <br /> Federal Lal� <br /> APPLICANT'S SIGNATURE: I 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 Racal ed by <br /> REHS: �1flYVll2 -0CG� Date_/2-0 /1?� Accountout � Date <br /> COMMENTS: <br /> J <br />