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Date run 10/6/2009 10:54:55AI SAN JOAOUIN COUNTY ENVIRONMENTAL HEAI-T'H DEPARTMENT Report 85021 <br /> Run by 5290 Pagel <br /> 1=of Facility Information as of 1016120ewW- <br /> Record Selection Criteria: Facility ID FA0010218 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN 1 Fed Tax ID <br /> Owner ID OW0015654 New Owner ID <br /> Owner Name PAUL TIEHM AUTOMOTIVE GRP INC <br /> Owner DBA <br /> Owner Address PO BOX 1417 <br /> LODI, CA 95241 <br /> Home Phone 209-365-7004 <br /> Work/Business Phone 209-483-6768 <br /> Mailing Address PO BOX 1417 <br /> LODI, CA 95241 <br /> Care of TIEHM, EUGENE P <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010218 <br /> Facility Name PAUL TIEHM AUTOMOTIVE GRP INC LI,I'I'-rntX lt ) I IL4 <br /> Location 1123 E VINE ST <br /> LODI, CA 95240 <br /> Phone 209-365-7004 <br /> Mailing Address PO BOX 1417 <br /> LODI, CA 95241 <br /> Care of PAUL TIEHM <br /> Location Code 02- LODI Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 04915006 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name PAUL TIEHM <br /> Title <br /> Day Phone 209-365-7004 <br /> Night Phone 209-483-6768 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account lD AR0017218 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner I Facility ! Account <br /> Account Name PAUL TIEHM AUTOMOTIVE GRP INC (Circle One) <br /> Account Balance as of 10/6/2009: $0.00 <br /> (Circle One) <br /> Transfer to Activellnaclve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONSNR PR0514236 EE0001422-ARIS CACAPIT Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO1PR0512506 EEOOOOD00-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0520164 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR,PR0510218 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2832-AST FAC 10 K-<I-100 K GAL CUMULATIVEPR0526955! EE0001422-ARIS CACAPIT Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO524827 EE5555555-Garrett Alias-Backus 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,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 Ordinate Codes andlor Standards and <br /> State andlor Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 I <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date ! ! <br /> Water System to be TRANS FERED: `$372.00= Amount Paid Date 1 I <br /> Payment Type Check Number Received by <br /> REHS: Date 1 I Account out: Date ld I D 6! 0'7 <br /> COMMENTS: pe"(_ (�YlN�� a-bb . <br /> 11eh-envlenvisionlreports15021.rpt ll�y <br />