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Date run 8/24/2015 2:19:53PR SAN JOf IN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 8/24/2015 <br />Record Selection Criteria: Facility ID FA0022273 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0018557 <br />Owner Name <br />David Adams <br />Owner DBA <br />Amount Paid Date <br />Owner Address <br />3850 N WILCOX RD G <br />Number <br />STOCKTON, CA 95215 <br />Home Phone <br />209-462-4264 <br />Work/Business Phone <br />209-931-4681 <br />Mailing Address <br />3850 Wilcox Rd Ste G <br />^ <br />� <br />nQ I�IIA' <br />Stockton, CA 95215 <br />Care of <br />ADAMS, DAIVD <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0022273 10609708 <br />Facility Name <br />Adams Automotive <br />Location <br />3850 Wilcox Rd Ste G <br />Stockton, CA 95215 <br />Phone <br />209-931-4681 x <br />Mailing Address <br />3850 Wilcox Rd Ste G <br />Stockton, CA 95215 <br />Care of <br />David Adams <br />Location Code <br />99 - UNINCORPORATED P <br />Bos District <br />002 - MILLER, KATHERINE <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0040656 <br />Mail Invoices to Account <br />Account Name David Adams <br />Account Balance as of 8/24/2015: $0.00 <br />1 <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 />Alt Phone <br />Fax <br />EMail : <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1920 - HMBP-Common Materials PR0538794 EE0008709 - JAMIE DE LA ROSA Active Y N A I D <br />2220 - SM HW GEN <5 TONS/YR PR0538795 EE0000005 - FATINAH ZAREEF Active 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 Codes and/or Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: <br />" $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: <br />Amount Paid Date <br />Payment Type Ch <br />Number <br />Rece' ed by <br />EHD Staff: <br />Account out: <br />Date /— <br />COMMENTS: <br />Vu �YZS <br />^ <br />� <br />nQ I�IIA' <br />cm m <br />In oi <br />IV�—/, <br />