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Date run 2/20/2013 11:13:29AI SAN A§UIN COUNTY ENVMONMENTAL HEA% DEPARTMENT Report 45021 <br /> Runb ' Pagel <br /> Facility Information as of 2/20/2013 <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 /> ownerAddress 6245 BURSON RD <br /> VALLEY SPRINGS, CA 95252 <br /> Home Phone 209-772-1785 <br /> Work/Business Phone 209-957-5226 <br /> Mailing Address 6245 BURSON RD <br /> VALLEY SPRINGS, CA 95252 <br /> Care of PAIZS, BYRON J <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0018096 <br /> Facility Name TULEBURG TOWING <br /> Location 2446 N WILCOX RD <br /> STOCKTON, CA 95215 <br /> Phone 209-931-6181 <br /> Mailing Address 2446 N WILCOX RD 435 / CD- <br /> STOCKTON, CA 95215 o-� 95215- 1 <br /> Care of PAIZS, BYRON J <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 10102174 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 AR0031831 New Account ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name TULEBURG TOWING (Circle One) <br /> Account Balance as of 2/20/2013: $623.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Element and Description Record ID Employee ID and Name Status New OwneR Delete <br /> 1921 HMBP-Regular-Primary Location PR0536641 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> -SM HW GEN<5 TONSNR PR0526727 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 SURCH,PRO534307 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,endror protect 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 Codes andlor Standards and Slate and'or <br /> Federal Lars. <br /> /' AA <br /> APPLICANTS 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 Receive <br /> REHS: Date / / Account out: Date <br /> COMMENTS: ^ <br /> eu � 2 �Z� � 1JJ <br />