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Date run 7/7/2008 9:24:58AM SAN SAN COUNTY ENVIRONMENTAL HT -I DEPARTMENT Report#5021 <br /> Run by ��/ Pagel <br /> Facility Information as of 7/7/L00S <br /> Record Selection Criteria: Facility ID FA0016202 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0013098 New Owner ID <br /> Owner Name BOB ZAMORA <br /> Owner DBA GO HYUNDAI KIA <br /> Owner Address 2929 AUTO CENTER DR <br /> STOCKTON, CA 95212 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-838-1211 <br /> Mailing Address 2929 AUTO CENTER DR <br /> STOCKTON, CA 95212 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0016202 <br /> Facility Name GO HYUNDAI KIA <br /> Location 2929 AUTO CENTER DR <br /> STOCKTON, CA 95212 <br /> Phone 209-838-1211 <br /> Mailing Address 2929 AUTO CENTER DR <br /> STOCKTON, CA 95212 <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 003 - MOW, VICTOR Fax <br /> APN 12802019 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 AR0028325 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility I Account <br /> Account Name BOB ZAMORA (Circle One) <br /> Account Balance as of 7/7/2008: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inaclve <br /> Program/Element and Description Record ID Employee ID and Name Status New Omer? Delete <br /> 2220-SM HW GEN<5 TONSNR PR0527711 EE0004636-GARRETT BACKUS Active Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0524111 Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO527170 EE0004680-NATALIA SUBBOTNIKO'Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anwor project specific,PHS/EHD hourly charges associated with this <br /> facility 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 Ordinace Codes and/or Standards and <br /> State anNor Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date I / <br /> COMMENTS: <br /> \\phs-ehsq)-n t\apps\envisions\reports\5021.rpt <br />