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Date ran 6/29/2016 11:10:10AI SAN JOAQUIN COU)LTY ENMONMENTAL HEALTH DEPARTMENT Report 45021 <br /> Run by Pagel <br /> Facility Information as of 6/29/2016 <br /> Record Selection Criteria: Facility ID FA0016552 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0013407 New Owner ID <br /> Owner Name BARAJAS, GRISELDA <br /> Owner DBA CORONA PM ROAD SERVICE <br /> OwnerAddress 1887 E 11TH ST <br /> STOCKTON, CA 95206 <br /> Home Phone 209-495-0768 <br /> Work/Business Phone 209-932-0598 <br /> Mailing Address 2327 MARIPOSA RD <br /> STOCKTON, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0016552 10185189 <br /> Facility Name CORONA PM ROAD SERVICE <br /> Location 2327 MARIPOSA RD <br /> STOCKTON, CA 95205 <br /> Phone 209-932-0598 x <br /> Mailing Address 2327 MARIPOSA RD <br /> STOCKTON, CA 95205 <br /> Care of Griselda Barajas <br /> Location Code Alt Phone <br /> BOB District Fax <br /> APN 17129016 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name Griselda Barajas <br /> Title Owner <br /> Day Phone 209-932-0598 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0029189 NewAccount ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility I Account <br /> Account Name CORONA PM ROAD SERVICE (Circle One) <br /> Account Balance as of 6/29/2016: $0.00 <br /> (Circle One) <br /> Transfer to Activellnacb,e <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 19 -HMBP-Regular-Primary Location PR0524649 EE0000006-HAZA SAEED Active Y N A I D <br /> 2220- M HW GEN�5 TONS/YR PR0538510 EE0000015-TIMOTHY ENGLE Active Y N A I D <br /> -WASTE TIRE SITE-EXEMPT PR0524826 EE0000060-JENNIFER FRASE Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0531397 Inactive Y N A I D <br /> LBILLI.NG and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all age,ander project specific,PHS/EHD hourly charges associated wrth this facility <br /> y will be billed to the pant IdentRed as the OWNER on Nis form. I also canny that all operations will be performed in accordance wfth all applicable Ordinance Codes and/or Standards and State andor <br /> LawsCkLCqt fD <br /> APPLICANTS SIGNATURE: Date I / <br /> Program Records to be TRANSFERED: •$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Ch k Number Received b <br /> EHD St Date__jjf7/_,X4/ Account out: Date V <br /> COMMENTS: <br /> Invoice#: <br />