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Date run 7/21/2009 8:55:38AN SAN,' QUIN COUNTY ENVIRONMENTAL HE "H DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 7/21/2uu� <br />Hecord Selection Criteria: Facility ID FA0013644 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0010757 <br />Owner Name <br />ZARIFAKIS, MATHIOS <br />Owner DBA <br />720 E LODI AVE <br />Owner Address <br />9708 ENCHANTMENT LN <br />Phone <br />STOCKTON, CA 95209 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />9708 ENCHANTMENT LN <br />Location Code <br />STOCKTON, CA 95209 <br />Care of <br />ZARIFAKIS, MATHIOS <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0013644 <br />Facility Name <br />MAT'S CAR REPAIR <br />Location <br />720 E LODI AVE <br />LODI, CA 95240 <br />Phone <br />209-367-9870 <br />Mailing Address <br />720 E LODI AVE <br />LODI, CA 95240 <br />Care of <br />ZARIFAKIS, MATHIOS <br />Location Code <br />02 - LODI <br />BOS District <br />004 - VOGEL, KEN <br />APN <br />04745013 <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 />pv- �tJ�rJ <br />10 S 3. a✓'rpwdP.d . <br />Loa i CA R5-240 <br />209 301- 101 <br />'120 V-- - Loa; /eve . <br />Sa �r ick„a <br />Alt Phone <br />Fax <br />EMail <br />I <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name MATHIOS ZARIFAKIS <br />Title <br />Day Phone 209-367-9870 <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0022800 New Account ID: <br />Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br />Account Name MAT'S CAR REPAIR (Circle One) <br />Account Balance as of 7/21/2009: $450.00 <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />2220 - SM HW GEN <5 TONS/YR PRO517990 EE0001422 - ARIS CACAPIT Active Y N A I D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO517991 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />2244 - PACT TRANSFER RECORD - OES PR0521048 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARPR0517992 EE0000000 - HAZ MAT SJC OES Inactive 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 <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 and/or Federal Laws. <br />APPLICANT'S 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 lay <br />REHS: N%-, Date 0R Account out: Date 7/y / <br />COMMENTS: <br />\\eh-env\envision\reports\5021. rpt <br />